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Ano rectal problems ppt
1. Ano rectal Problems
• Presented By –
Prof.Dr.R.R.Deshpande
(M.D in Ayurvdic
Medicine & M.D. in
Ayurvedic Physiology)
• www.ayurvedicfriend.c
om
• Mobile – 922 68 10 630
• professordeshpande@g
mail.com
2/6/2017 Prof.Dr.R.R.Deshpande 1
3. Contents of this PPT
• 7) Piles
• 8) Fissure in Ano
• 9) Fistula in Ano
• 10) Prolapse of Rectum
• 11) Pilonidal Sinus
• 12) Stricture of Anus & Rectum
2/6/2017 3Prof.Dr.R.R.Deshpande
4. Contents of this PPT
• 13) Condyloma
• 14) Carcinoma of Rectum
• 15) Pruritus Ani
• 16) Ano Rectal pain
• 17) Anal Incontinence
• 18) Proctitis
• 19) Rectal Polyp
• 20) Ayurvedic Treatments
2/6/2017 4Prof.Dr.R.R.Deshpande
5. Anatomy of Anorectal region –
Rectum
• Distal part of colon .Sogmoid colon above &
anal canal below
• 3 cardinal features ( Taeniae coli ,
Haustrations, Appendices epiploicae ) of
colon are absent
• Pelvic organ – situated in posterior part of
lesser pelvis – in front of lower 3 sacral
vertebrae
2/6/2017 5Prof.Dr.R.R.Deshpande
6. Anatomy of Anorectal region –
Rectum
• Diameter – 5 inches .Lower part is dilated to
form Rectal Ampulla
• Lower 1/3rd of rectum is devoid of peritoneum
• Fold of peritoneum between –urinary bladder
& rectum ,in males – Recto vesical pouch
• Fold of peritoneum between – Uterus ,cervix
,vagiba & rectum ,in Females – Recto uterine
pouch
2/6/2017 6Prof.Dr.R.R.Deshpande
7. Anatomy of Anorectal region –
Rectum
• Blood supply – Superior rectal
,Medial rectal, Median sacral artery
• Venous drainage – Superior & Middle
rectal vein
• Nerve supply – Sympathetic from L1
& 2 , Parasympathetic from S 2,3,4
2/6/2017 7Prof.Dr.R.R.Deshpande
8. Anatomy of Anorectal region –
Rectum
• Applied Anatomy –
• PR Examination for BPH etc
• Examination of Rectal mucosa –
Proctoscopy or Sigmoidoscopy
• Prolapse of Rectum – Rectum comes
out through anus
2/6/2017 8Prof.Dr.R.R.Deshpande
9. Anatomy of Anal canal
• Terminal part of colon .Situated below
the Pelvic diaphragm ,in anal triangle of
peritoneum ,between right & left ischio
rectal fossa .3.8 cm long .Extends from
Ano rectal junction to anus
• 3 parts – Upper mucous part ,Middle
transitional zone, Lower cutaneous part
2/6/2017 9Prof.Dr.R.R.Deshpande
10. Anatomy of Anal canal
• 1 . Upper mucous part – 15 mm long ,lined by
mucous membrane .Mucous membrane
shows 6 to 10 vertical folds – Anal column
• Lower end of anal column are united to each
other by transverse fold of mucous
membrane = Anal valves
• Anal valves together forms ,a transverse line
= Pectinate line
2/6/2017 10Prof.Dr.R.R.Deshpande
11. Anatomy of Anal canal
• 2 . Middle part or Transitional zone –
15 mm long ,Do not contain anal
columns .
• White line of Hilton = Lower limit of
Pecten
2/6/2017 11Prof.Dr.R.R.Deshpande
12. Anatomy of Anal canal
• 3 . Cutaneous part -- 8 mm long .Contain
sweat & sebaceous glands
• Muscles of Anal canal – Internal anal
sphincter ( Involuntary) & External anal
sphincter ( Voluntary) – subcutaneous part ,
superficial part , deep part
2/6/2017 12Prof.Dr.R.R.Deshpande
13. Anatomy of Anal canal
• Nerve supply –External anal sphincter –
supplied by Inferior rectal nerve & 4th sacral
nerve
• Blood supply --- Anal canal ,above the
Pectinate line is supplied by – superior rectal
artery & below the pectinate line by –
Inferior Rectal artery
2/6/2017 13Prof.Dr.R.R.Deshpande
14. Anatomy of Anal canal
• Venous drainage –
• 1.Internal Rectal venous plexus
• ( Haemorrhoidal Plexus ) – Lies in submucosa
of the anal canal .Drains into superior rectal
vein .Internal rectal venous plexus is an
important site of Porta caval Anastomasis
• The veins present at 3 ,7 & 11 o clock are
potential sites for primary Internal piles
2/6/2017 14Prof.Dr.R.R.Deshpande
15. Anatomy of Anal canal
• External Rectal venous plexus – Freely
communicates with the Internal rectal venous
plexus
• Anal veins – Arranges radially around the
anal margin .Excessive straining during
defaecation rupture the anal veins – forms
sub cutaneous haematoma = External Piles
2/6/2017 15Prof.Dr.R.R.Deshpande
16. Anatomy of Anal canal
• Applied Anatomy –
• 1.Internal or True Piles – Dilation of Internal
Rectal venous plexus – classified into 2 groups
• Primary True Piles – Dilation of Internal Rectal
venous plexus at 3,7,& 11 o clock
• Secondary True Piles – Dilation of other than
above sites
2/6/2017 16Prof.Dr.R.R.Deshpande
17. Anatomy of Anal canal
• Applied Anatomy –
• 2. External or False Piles – Rupture of anal
veins ,causing sub cutaneous haematoma
.External Piles – No bleeding ,but painful
• 3.Anal Fissure – Rupture of anal valve .Painful
with blood sticked to faeces
2/6/2017 17Prof.Dr.R.R.Deshpande
18. Anatomy of Anus
• 4.Fistula in Ano – Abnormal epithelized tract
,containing 2 cavities or 1 cavity with the
exterior outer opening of anal canal .4 cm
below & in front of tip of coccyx
• Skin around anus is pigmented
• Thrown into radiating folds .Contain ring of
Apocrine gland – keeping anus moist with
typical foul smell
2/6/2017 18Prof.Dr.R.R.Deshpande
19. 2/6/2017 Prof.Dr.R.R.Deshpande 19
Acute Constipation causes
• 1) Local pain at anus – painful fissure, perianal
abscess.
• 2) Elderly bed ridden patient.
• 3) Pregnancy.
• 4) Constipation with colicky pain in abdomen,Board
like rigidity, abdominal distention or vomiting-
Intestinal obstruction. (hyper peristalsis) or paralytic
ileus (No peristalsis) or Acute Abdomen.
• 5) Idiopathic functional constipation.
21. 2/6/2017 Prof.Dr.R.R.Deshpande 21
Acute Constipation- Treatment 1
• 1) For perianal abscess – Incision & drainage.
• 2) For fissure in Ano –
- Local – Xylocaine oint.
- Cap Mox – 500 mg TDS.
- Tab Tini – 300 mg – 1 BD.
- Tab Voveron – 100 mg – 1 BD.
- Tab Triphala vati – 2 H.S.
22. 2/6/2017 Prof.Dr.R.R.Deshpande 22
Acute Constipation- Treatment 2
• 3) For idiopathic constipation –
- Tab Herbolax (Himalaya) 3 H.S or
Abhayaristha – 3 tsf with equal quantity of
water-BD.
• 4) For Acute Abdomen –
- Admit Immediately.
23. 2/6/2017 Prof.Dr.R.R.Deshpande 23
Chronic Constipation – causes 1
(Habitual Constipation)
• Lack of exercise (especially
abdominal muscle exercises – poor
abdominal muscle tone.)
• Lack of roughage (Green vegetables,
fruits, raw bananas) in Diet.
24. 2/6/2017 Prof.Dr.R.R.Deshpande 24
Chronic Constipation causes 2
(Habitual Constipation)
• Drinking Less water or beverages.
• Tobacco, Mawa, smoking.
• Drugs (Anti-hypertensives, antacids,
Iron, NSAIDS).
25. 2/6/2017 Prof.Dr.R.R.Deshpande 25
Chronic Constipation causes 3
(Habitual Constipation)
• Insulting Natural calls.
• Pain at anus (Fissure, anal stricture,
Growth).
• Bed ridden patients
26. 2/6/2017 Prof.Dr.R.R.Deshpande 26
Chronic Constipation causes 4 (Habitual
Constipation)
• 4) In Elderly alternate constipation &
Diarrhoea or Constipation with P /R
bleeding ---- R / O -- Malignancy of colon
or rectum
• 5) Long term use of Laxatives or Enema(
Loss of Muscle Tone)
36. Congenital Problems
• 1) Post anal dermoid cyst
• 2) Sacro-Coccygeal Teratoma
• 3) Imperforated Anus
2/6/2017 36Prof.Dr.R.R.Deshpande
37. 1) Post anal dermoid cyst
• Situated behind anus & in front of coccyx
& sacrum.
• May be seen in adults.
• Soft cystic swelling
• Cyst may get infected & sinus may form
• Treatment - Excision
2/6/2017 37Prof.Dr.R.R.Deshpande
38. 2) Sacro-Coccygeal Teratoma
• Teratoma at sacro-coccygeal region.
• Most common Tumour seen in neonatal baby.
• Firm in consistency
• It is usually seen as a big swelling & may
change into malignancy.
• Treatment - Excision
2/6/2017 38Prof.Dr.R.R.Deshpande
39. 3) Imperforated Anus
• Common congenital abnormality
• Imperfect fusion of a hind-gut &
lower part of anal canal
(proctodeum)
2/6/2017 39Prof.Dr.R.R.Deshpande
40. Anal stenosis
• The whole of anal canal is narrow or
anus is microscopic with a minute
opening
• The patient presents passing of a
meconium with pain
• Treatment - Regular dilatation of anus.
2/6/2017 40Prof.Dr.R.R.Deshpande
42. Ano-Rectal Agenesis
• A blind rectal pouch lies just above the pelvic
floor.
• In the male the fusion is attached to bladder &
often there is a fistula between rectum &
bladder known as rectovesical fistula.
• In females, fistula may be present with
posterior fornix.
• In this variety, sometimes gas or meconium is
present in urine.
2/6/2017 42Prof.Dr.R.R.Deshpande
46. Piles
• Dilated plexus of hemorrhoidal veins in
relation to anal canal
• Inflammation of anal cushion
• (Anal cushion is formed by venules,
arterioles, arterio venule junction,
smooth connecting tissues & mucosa of
anal canal.)
2/6/2017 46Prof.Dr.R.R.Deshpande
47. Piles –Causes
• 1) Standing or prolong sitting ( blood has to flow
against gravity )
• 2) Defaecation - The veins passes through mucosa of
anus & rectum .They get constricted if there are hard
stool
• 3) Excessive straining
• 4) Absence of valves or congenital weak veins
• 5) Pregnancy - Due to the pressure effect & hormones
which relaxes muscles of the vein.
• 6) Carcinoma of rectum due to backpressure.
• 7) Portal Hypertension
2/6/2017 47Prof.Dr.R.R.Deshpande
48. Classification of Piles – Antomical
Type Site of Piles
Internal
Hemorrhoids
Situated above dentate line & covered with
mucosa
External
Hemorrhoids
situated below dentate line & covered with
skin.
Interno
external
Hemorrhoids
situated above & below dentate line &
covered with mucosa & skin
2/6/2017 48Prof.Dr.R.R.Deshpande
49. Classification of Piles – Position
Type of Pile Position
Primary
Piles
situated at --11, 7 & 3 o’clock position
Secondary
Piles
situated at -- 1 o’clock, 2 o’clock
2/6/2017 49Prof.Dr.R.R.Deshpande
50. Classification of Piles – Prolapse
Degree Condition of Piles
First Only bleeding but do not come out of anus
Second Protrude during defaecation but goes
automatically inside the anus
Third Protrude out & has to pushed inside manually
Forth Protrude out ,not only during defaecation but
even during coughing, sneezing, laughing &
remains outside .
2/6/2017 50Prof.Dr.R.R.Deshpande
51. Piles – Clinical Features
• 1) Painless Bleeding - bleeding after
defecation, which is dropwise or splash in the
pan.
• External piles doesn’t bleed usually but gives
only pain
• 2) Protrusion of Mass 3) Discharge of Mucus
• 4) Itching or Irritation 5) Soiling of under
garments
2/6/2017 51Prof.Dr.R.R.Deshpande
52. Piles – P/R Examination
• Internal piles can’t be felt unless they
are secondary infected
• Proctoscopy - Internal piles bulge
into lumen of proctoscope which are
in purple colour
2/6/2017 52Prof.Dr.R.R.Deshpande
55. Piles – Complications
• Pain – when there is secondary infection.
• Thrombosis
• Ulceration
• Suppuration
2/6/2017 55Prof.Dr.R.R.Deshpande
56. Piles – Medical Treatment
• Purgatives.
• Sitz bath
• Local -- Xylocaine Jelly if pain.
• Tab Voveron LA – 1 BD.
• Antibiotics --- if infection is suspected
• Laxatives – To avoid straining
2/6/2017 56Prof.Dr.R.R.Deshpande
57. Piles – Surgical Treatment
• Lord’s dilatation
• Injection therapy
• Baroon band ligation
• Cryo surgery
• Infra Red coagulation
• Transfix & ligation
• Hemorrhoidectomy
• Ksharsutra therapy
2/6/2017 57Prof.Dr.R.R.Deshpande
58. Dry Piles
• (i) Kankayan Guti -- 2 Tab. 3 times a day
• (ii) Triphala Guggulu ---- 2 Tab. 3 times a
day
• (iii) Abhayarishtha -- 4 tablespoon with
equal amount of water 2 times after
meals.
2/6/2017 58Prof.Dr.R.R.Deshpande
59. Dry Piles
• (i) Kutaja Ghana vati -- 2 Tab. 3 times a day
• (ii) Arogyavardhini -- 2 Tab. 3 times a day
• (iii) Amrutbhallatakavleha -- 1 tablespoon
each morning
• (iv) Gandharva Haritaki Churna -- 1
tablespoon at bed time with warm water.
2/6/2017 59Prof.Dr.R.R.Deshpande
60. Dry Piles – Locally
• (i) Apply Sarjarasa malahar or
Shatadhout ghruta locally
• (ii) Fumigate with Guggulu, Vacha,
Dhoopa, Owa etc.
• (iii) Apply Chukra Taila and advice Sit’z
bath.
2/6/2017 60Prof.Dr.R.R.Deshpande
61. Bleeding Piles
• (i) Bolabaddha Rasa -- 2 Tab. 3 times a
day
• (ii) Samasharkara Churna -- 2 Tsf 3 times
a day
• (iii) Triphala Churna -- 2 tablespoon at
bed time with ghee and warm water
2/6/2017 61Prof.Dr.R.R.Deshpande
62. Bleeding Piles
• (i) Praval Vati (HP) -- 2 Tab. 3 times a
day
• (ii) Kamaduha Vati (HP)-- 2 Tab. 3
times a day
• (iii) Kutajarishtha --4 tablespoon
with equal amount of water times
after meals.
2/6/2017 62Prof.Dr.R.R.Deshpande
63. Bleeding Piles
• (i) Pilex (Himalaya) -- 2 Tab. 3 times a day.
• (ii) Pyroids (B) 2 Tab.-- 3 times a day.
• OR
• (i) Arshonyl (C) --2 Tab. 3 times a day.
• OR
• (i) Nagkeshar Churna – 1 table spoon with
butter and warm water 3 times a day.
2/6/2017 63Prof.Dr.R.R.Deshpande
64. Bleeding Piles
• Local Application :-----
• (i) Shatadhouta Ghruta
• (ii) Pilex, Arshonyl ointment.
2/6/2017 64Prof.Dr.R.R.Deshpande
65. Bleeding Piles-Regimen
• (i) Use of Suran (only for Dry piles) and
Takra (butter milk) is advisable. If
excessive bleeding, instead of Suran,
take black resins 30 to 40 each day.
• (ii) Old rice, wheat, Takra, Shunth (dry
ginger powder), Padaval etc. are good for
piles.
2/6/2017 65Prof.Dr.R.R.Deshpande
66. Bleeding Piles -Regimen
• (iii) Stay away from spicy, hot food
and curd.
• (iv) Sitting on uneven surface, or in
the same position for long, riding a
bike, travelling, forcible bowel
movements are to be avoided.
2/6/2017 66Prof.Dr.R.R.Deshpande
67. Fissure in Ano
• Longitudinal ulcer in the lower end
of anal canal
• Mostly due to constipation
• Most painful condition in the anal
region
• Seen in young adults
2/6/2017 67Prof.Dr.R.R.Deshpande
68. Fissure –Common site
• In males is 90% at the posterior &
10% at the anterior site
• In females during pregnancy due to
tear of perineum resulting in loose
support to the anterior anus – So
common site is anterior 60% & 40%
at posterior site.
2/6/2017 68Prof.Dr.R.R.Deshpande
69. Types of Fissure in Ano
• 1) Primary --- fissure is situated at midline of
anus
• 2) Secondary -- situated other than midline
of anus
• Seen in secondary diseases like ulcerative
colitis, Crohn’s disease, malignancy, syphilis,
diabetes mellitus & trauma.
2/6/2017 69Prof.Dr.R.R.Deshpande
70. Fissure in Ano –Clinical features
• 1) Pain -- Remain after defecation constant up
to 4 hrs ( burning or cutting in nature)
• 2) Hard stool -- pellet like
• 3 )Sentinel piles -- Always present in fissure in
ano. They are due to mal union, fibrosis of
fissure & chronicity
2/6/2017 70Prof.Dr.R.R.Deshpande
71. Fissure in Ano –Clinical features
• 4 )Bleeding -- Negligible in fissure .Bleeding is
streak like on stool matter on a toilet paper.
Sometimes as a drop.
• 5 )Abscess -- Due to injury to anal gland,
infection results in pus formation.
• 6 ) Itching -- Due to continuous watery
discharge from fissure, perianal area remains
wet .This results in irritation or itching in
perianal region
2/6/2017 71Prof.Dr.R.R.Deshpande
72. Fissure in Ano
• On Inspection of Anal region -- fissure is
visible in midline.
• P/R Digital examination – is difficult In
acute condition ,due to pain
• In chronic condition -- fissure is palpable
& tenderness & spasm of sphincter can
be noted
2/6/2017 72Prof.Dr.R.R.Deshpande
73. Fissure in Ano – Medical Treatment
• Locally -- Xylocaine jelly for local pain
relief
• Laxatives
• Sitz bath
• NSAIDs ,Antibiotic
• Inferior haemorrhoidale nerve block may
be tried for relief of pain.
2/6/2017 73Prof.Dr.R.R.Deshpande
74. Fissure in Ano – Surgical Treatment
• Lord’s Dilatation
• Fissurectomy
• Sphincterectomy
2/6/2017 74Prof.Dr.R.R.Deshpande
75. Stretching of Anal canal
• Lords procedure of anal dilatation is the
easiest method to dilate the sphincter of
anal canal under general or spinal
anaesthesia
• Patient in a Lithotomy position
• There may be some faecal incontinence
for a few days
2/6/2017 75Prof.Dr.R.R.Deshpande
76. Fissurectomy
• A triangular incision (v shaped) is made
with a surgical knife, starting from anal
margin on each site of the fissure
• Edges of fissure sutured with 2-0 chromic
catgut with interrupted suture
• Complication --- Anal stricture
2/6/2017 76Prof.Dr.R.R.Deshpande
77. Anorectal fissure
• (i) Chandrakala Rasa 2 Tab. 3 times a day.
• (ii) Mauktika Kamadudha 1- 2 Tab. 3 times a day.
• (iii) Abhayarishtha 4 tablespoon with equal
amount of water 2 times after meals
• Local Application :
• (i) Shatadhouta Ghruta/ Kailas Jeevan
• (ii) Jatyadi Ghruta/Taila
• It is always better to consult a specialist if no
improvement is noted
2/6/2017 77Prof.Dr.R.R.Deshpande
78. Advice for Ano Rectal diseases
• 1) Avoid Constipation
• 2) Avoid Straining in toilet
• 3) Avoid chilly, spicy, non vegetarian
• 4) Avoid prolonged sitting, standing
& walking
2/6/2017 78Prof.Dr.R.R.Deshpande
79. Advice for Ano Rectal diseases
• 5) Keep Anorectal part clean & dry. This
area should be washed with diluted anti
septic solution like savlon or KMnO4 (sitz
bath)
• 6) Take a lot of liquids & butter milk.
• 7) Eat fruits like Grapes, Figs & Green
leafy vegetables which will help for easy
evacuation of stools
2/6/2017 79Prof.Dr.R.R.Deshpande
80. Fistula - in - Ano
• Fistula = Pipe or Tube
• Abnormal communication of
unhealthy granulation tissue
between anal canal or rectum with
external perianal skin
2/6/2017 80Prof.Dr.R.R.Deshpande
81. Fistula - in – Ano –Types
• 1) Internal fistula
• 2) External fistula
2/6/2017 81Prof.Dr.R.R.Deshpande
82. Fistula - in – Ano – Causes
• 1)Due to persistent anal gland infection which
results in ano rectal abscess, rupture inside or
outside resulting in fistula
• 2) Tuberculosis
• 3) Ulcerative colitis
• 4) Crohn’s disease
• 5) Carcinoma of Rectum
• 6) Diabetes mellitus
2/6/2017 82Prof.Dr.R.R.Deshpande
83. Fistula - in – Ano- Classification 1
• 1) Low anal fistula - Internal
opening below the ano rectal
ring
• 2) High anal fistula - Internal
opening above ano rectal ring
2/6/2017 83Prof.Dr.R.R.Deshpande
84. High & Low level Fistula
2/6/2017 84Prof.Dr.R.R.Deshpande
85. Fistula - in – Ano- Classification 2
• 1) Sub cutaneous
• 2) Sub mucosal
• 3) Pelvic rectal
2/6/2017 85Prof.Dr.R.R.Deshpande
86. Goodsall’s Rule (1900)
• 1) If the external opening is anterior
to an imaginary line within 3.75 cm
from mid point of the anus then -----
• The fistula runs straight (directly)
into the anal canal.
2/6/2017 86Prof.Dr.R.R.Deshpande
87. Goodsall’s Rule (1900)
• 2) If the external opening is situated
posterior to that line then -----
• The track usually will curve &
internal opening will be on the
midline posterior of the anal canal (6
o’clock).
2/6/2017 87Prof.Dr.R.R.Deshpande
88. Goodsall’s Rule (1900)
• 3) When external opening is anterior
but situated more than 3.75 cm
away from anus, then ---
• Track will curve & end in midline
posterior in anus.
2/6/2017 88Prof.Dr.R.R.Deshpande
90. Fistula in Ano –Clinical Features
• Persistent, purulent, thick discharge,
which keeps the part, always wet
• Pus discharge stained with blood
• Intermittent pain with relation to
discharge
• Internal opening felt as a buttonhole on
digital examination
2/6/2017 90Prof.Dr.R.R.Deshpande
91. Types of Fistula
• External Blind Fistula - External
opening present but internal
opening is absent
• Internal Blind Fistula - Internal
opening present but external
opening is blind or absent.
2/6/2017 91Prof.Dr.R.R.Deshpande
92. Examination of Fistula
• Inspection of peri anal region -- External
opening is visible
• Direction of anus is palpable towards anus or
rectum.
• Probing - It is carried out to see weather
internal opening is complete or external
opening is complete.
• Methylene Blue dye is used
2/6/2017 92Prof.Dr.R.R.Deshpande
93. Treatment of Fistula in Ano
• In acute stage antibiotic should be given
after pus culture & sensitivity test,
• Warm Sitz’s bath
• Laxative & NSAIDs are given like Tab
Combiflam or Voveron LA 100 mg BD
• Surgical -- Injection therapy or
Fistulotomy or Fistulectomy
2/6/2017 93Prof.Dr.R.R.Deshpande
94. Benefits of Ayurvedic Kshar Sutra
• 1) Minimum trauma
• 2) No tissue loss
• 3) No incontinence ( So specially useful in High
level Fistula)
• 4) Cost is less
• 5) It cuts & heals from the base ( Like
Chemical Cautery)
• 6) Very narrow & fine scar
2/6/2017 94Prof.Dr.R.R.Deshpande
96. Benefits of Ayurvedic Kshar Sutra
• 7) No bleeding or minimum bleeding
occurs
• 8) Low quality anesthesia is required
• 9) Minimal hospital stay
• 10) Recurrence rate is very low
2/6/2017 96Prof.Dr.R.R.Deshpande
97. Prolapse of Rectum
• Protrusion of a mucus membrane or
wall of rectum outside the anal
verge is known as prolapse of rectum
or Procidentia
• Common in children & old persons
2/6/2017 97Prof.Dr.R.R.Deshpande
98. Partial Prolapse
• The prolapse in which
protrusion is less than 5 cm
outside the anal verge is
known as partial or mucosal
prolapse.
2/6/2017 98Prof.Dr.R.R.Deshpande
99. Partial Prolapse-Causes
• It may be due to undeveloped sacral curvature
• Constipation.
• Mostly seen after an episode of whooping cough
or after acute attack of diarrhoea
• Loss of fat in ischio-rectal fossa, which support to
Rectum
• Due to delivery trauma or tear of perineum.
• Treatment -- Digital Reposition
2/6/2017 99Prof.Dr.R.R.Deshpande
100. Complete Prolapse
• Protrusion of rectum more than 5
cm or rectal wall outside the anal
verge
• Seen in females associated with
uterus prolapse
2/6/2017 100Prof.Dr.R.R.Deshpande
101. Complete Prolapse – Causes
• As age advances muscles become weak
due to degeneration & results in
prolapse of rectum
• Straining due to habitual constipation
• Mostly this type of prolapse is associated
with blood & mucus discharge
2/6/2017 101Prof.Dr.R.R.Deshpande
103. Rectal Prolapse
• (i) Insert prolapsed rectum inside
• (ii) Use Chukra Oil / Mushaka Oil for
lubrication
• (iii) Make a tight bandage with above
said oils over the rectum
2/6/2017 103Prof.Dr.R.R.Deshpande
105. Rectal Prolapse
• Note : Find out the cause, more often is
loose motions . treat the disease
properly.
• (i) Do not force yourself for evacuating
the bowels.
• (ii) Do not suppress natural urges like
Micturition or passing the stools.
2/6/2017 105Prof.Dr.R.R.Deshpande
106. Pilonidal Sinus
• Pilus = Hairs & Nidus = Nest
• Nest of hairs into skin in the inflammatory
skin known as Pilonidal Sinus
• Also known as ‘Jeep Bottom Disease –
Because it was more common in Jeep Drivers
at the time of II nd World War.
• Common in hairy person at the age of puberty.
2/6/2017 106Prof.Dr.R.R.Deshpande
107. Pilonidal Sinus
• In western countries most
commonly seen in toilet paper users
• Sinus is related to subcutaneous
tissue & rarely reaches to the bone &
it is not related to anus
2/6/2017 107Prof.Dr.R.R.Deshpande
108. Pilonidal Sinus
• Sinus has one or more openings
• Typically projecting hairs from its mouth – This
is a cardinal sign of pilonidal sinus.
• Clinical features -- painful swelling, tenderness,
continuous discharge
• High recurrence.
• Sinogram confirms the diagnosis
• Treatment -- excision of sinus with bunch of hairs
• Healing occurs by secondary intension.
2/6/2017 108Prof.Dr.R.R.Deshpande
110. Stricture of Anus & Rectum
• Congenital --- Narrowing of lumen
occurs at level of anal membrane
• Traumatic -- Injury to rectum during
sphincterectomy
,hemorrhoidectomy, excision of
polyp.
2/6/2017 110Prof.Dr.R.R.Deshpande
111. Stricture of Anus & Rectum
• Inflammation --- which may be due to --
• Tuberculosis
• Ulcer
• Ulcerative colitis
• Crohn’s disease
• syphilitic ulcer
• These causes --- stricture during healing
process of ulcer
2/6/2017 111Prof.Dr.R.R.Deshpande
112. Stricture of Anus & Rectum
• Neoplastic --- Annular & ulcerative
carcinoma
• Miscellaneous --- Persistent internal
sphincter contracture due to
constipation.
2/6/2017 112Prof.Dr.R.R.Deshpande
113. Stricture of Anus & Rectum –Treatment
• Surgical treatment is unsatisfactory So
better try to prevent stricture formation
• Patients are advised for -- frequent
digital dilatation or anal dilator, after
anus & rectum operations during healing
process
2/6/2017 113Prof.Dr.R.R.Deshpande
114. Condyloma (Genital Warts)
• Causative organism is HPV (Human
Papilloma Virus)
• Transmission is usually sexual who
practices anal intercourse or male
homosexual, Syphilis, Gonorrhea,
AIDS
2/6/2017 114Prof.Dr.R.R.Deshpande
115. Condyloma –Clinical features
• The growth looks like cauliflower
• Mass is pedunculated or sessile
• Protrusion of mass
• Located on perianal skin like penis, vulva,
• vagina & cervix
• Diagnosis is confirmed by Biopsy
2/6/2017 115Prof.Dr.R.R.Deshpande
116. Condyloma –Clinical features
• Pruritus
• Wetness
• Discomfort
• Treatment –
• Local application of caustic
• Local excision of condylomata
2/6/2017 116Prof.Dr.R.R.Deshpande
119. CA Rectum – Clinical Features
• Increase in constipation (early
symptom) or Alternate Constipation
& Diarrhoea
• Painless bleeding -- maroon color
(early symptom)
• Sense of incomplete defecation
• Tenesmus
2/6/2017 119Prof.Dr.R.R.Deshpande
120. CA Rectum – Clinical Features
• Mucus discharge with stool
• Loss of appetite & weight
• Pain is last symptom
• Abdomen distension due to obstruction
• Metastasis signs are -- Ascites, Jaundice,
Backache, enlarged lymph nodes,
hemoptysis
2/6/2017 120Prof.Dr.R.R.Deshpande
121. CA Rectum– Examination
• P/R Examination -- should be done in every case
of PR bleeding
• An indurated growth or ulcer can be felt
• After removing of finger it is stained with blood
• Proctoscopy - Bleeding ulcer or growth may be
visible.
• Colonoscopy
• Biopsy
2/6/2017 121Prof.Dr.R.R.Deshpande
123. CA Rectum - Duke’s Classification
• a) Marking ‘A’ - Growth is involved in rectum
& anus
• b) Mark ‘B’ - Growth beyond rectal wall but
lymph nodes aren’t enlarged
• c) Mark ‘C’ - Lymph nodes are enlarged
• C1 – Local & C2 - In course of circulation.
• Treatment -- Permanent Colostomy
2/6/2017 123Prof.Dr.R.R.Deshpande
124. Bleeding per rectum-Causes
• Congenital - Rectal polyp
• Traumatic - Injury to rectum or anus
• Fissure in Ano ( Severe pain with
bleeding)
• Bleeding Piles ( Dropwise or splash of
bleeding)
• Fistula in Ano ( Blood with mucus)
2/6/2017 124Prof.Dr.R.R.Deshpande
126. Bleeding per rectum-Causes
• Neoplastic –
• Tumor of intestine
• Carcinoma of colon or rectum or anus
• Miscellaneous - Piles Prolapse Fistula
• Drugs Group 1) Anti-coagulant 2) Endo
Methacin 3) Chloroquine 4) Aspirin 5) Cortico-
steroids 6) Phenyl Butazone
2/6/2017 126Prof.Dr.R.R.Deshpande
127. Bleeding per rectum
• For any kind of per rectal bleeding use
following symptomatic treatment
• Chandrakala Rasa 50 mg. + Praval
Bhasma 50 mg. + Mauktika Bhasma 50
mg. + Amalaki Churna 500 mg. +
Nagkeshar Churna 25 mg. 3 times a day
2/6/2017 127Prof.Dr.R.R.Deshpande
128. Pruritus Ani with Discharge -Causes
• Piles
• Condylomata
• Polyps
• Carcinoma of anus
• Any growth
• Fissure
• Fistula
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129. Pruritus Ani with vaginal problems
• Trichomonal vaginitis
• Cervicitis
• Leucorrhoea
2/6/2017 129Prof.Dr.R.R.Deshpande
130. Pruritus Ani with worms & Fungus
• Threadworm
• Monilial infection
• Tinea cruris
2/6/2017 130Prof.Dr.R.R.Deshpande
131. Pruritus Ani with skin problems
• Allergic dermatitis
• Psoriasis
• Eczema
2/6/2017 131Prof.Dr.R.R.Deshpande
132. Pruritus Ani with Metabolic problems
•Obstructive Jaundice
• Diabetes mellitus
2/6/2017 132Prof.Dr.R.R.Deshpande
133. Pruritus Ani –Other causes
• Excess or frequent use of laxative
drugs -- causes excessive secretions
• Synthetic or rough inner garments
• Poor hygiene of perianal region.
2/6/2017 133Prof.Dr.R.R.Deshpande
134. Anal Itching –Summary
• Itchy skin around anus
• Causes –
• Skin diseases like scabies ,Tinea
• Allegic reactions to under garments
• Uncontrolled DM
• Fissure ,Fistula in ano ,Thread worms
• Liver diseases
• Cancer
2/6/2017 134Prof.Dr.R.R.Deshpande
136. Ano Rectal Pain
• All the anal conditions below dentate line are
painful because supplied by spinal nerve
segment
• Conditions ,above dentate line are painless as
long because they are supplied by
autonomous nervous system
• These painless lesion can become painful
,when they spread beyond rectal wall by
inflammation & infiltration.
2/6/2017 136Prof.Dr.R.R.Deshpande
137. Various painful Ano Rectal conditions
Sr.No Condition Cause
1 Continuous Throbbing pain Perianal or Anorectal
abscess
2 Sharp cutting, burning, shooting pain Fissure in Ano
3 Pain is intermittent Chronic sinus or Fistula
4 Painless ulcer Syphilitic
5 Lower Abdomen Pain Obstructive
lesion within the rectum
6 Tenesmus Rectal growth
2/6/2017 137Prof.Dr.R.R.Deshpande
138. Perianal haematoma
• (i) Triphala Guggulu 2 Tab. 3 times a day
• (ii) Gokshuradi Guggulu 2 Tab. 3 times a
day
• (iii) Vatavidhvans Rasa 1 Tab. 3 times a
day
• (iv) For local application . Dashang Lepa
2/6/2017 138Prof.Dr.R.R.Deshpande
139. Abscess (Peri anal)
• (i) Sukshma Triphala (AYR) 2 Tab. 3 times a day.
• (ii) Gandhak Rasayana 2 Tab. 3 times a day.
• (iii) Septilin 2 Tab. 3 times a day.
• (iv) Triphala Guggulu 2 Tab. 3 times a day.
• (v) Local application : Lepa Goli
• Note : With the treatment, if there is pus in the
absess incision and drainage is a better choice, if
no facility refer to a specialist.
2/6/2017 139Prof.Dr.R.R.Deshpande
140. Anal incontinence
• Anal incontinence is defined as loss on control
of defecation act
• Anorectal ring is the important structure to
control defaecation act
• Anorectal ring marks the junction between the
rectum & anal canal
• It is formed by pubo rectalis, highest part of
internal sphincter, longitudinal muscle &
external part of sphincter
2/6/2017 140Prof.Dr.R.R.Deshpande
144. Anal incontinence –Treatment
• Temporary incontinence – Reassurance &
perineal exercises to improve the tone of
internal & external sphincter.
• Suturing of the torn sphincter
• Permanent incontinence – inter sphincteric
repair of puborectalis & plication of the
external sphincter
2/6/2017 144Prof.Dr.R.R.Deshpande
145. Proctitis
• Inflammation of rectal mucosa with
inflammation of colon & anal canal
• Types –
• Acute or chronic
• non specific or specific
2/6/2017 145Prof.Dr.R.R.Deshpande
150. Proctitis
• Treat the root cause
• Antibiotics
• Anti amoebic
• Retention enema of prednisolone
• Tab salazopyrin
2/6/2017 150Prof.Dr.R.R.Deshpande
151. Rectal polyp
• Any circumscribed mass of tissue that
arises from mucosa & protrudes into the
lumen of rectum
• Common in children in the first decade
of life
• May appear in adults also
• Rare after 30 years of age
2/6/2017 151Prof.Dr.R.R.Deshpande
153. Rectal polyp –Clinical Features
• Streaks of blood on the stool or sometimes
profuse bleeding
• Protrusion of mass during defecation
• Mucous discharge
• Anaemia due to recurrent bleeding
• Tenesmus
• Usually it is painless but painful if infected
2/6/2017 153Prof.Dr.R.R.Deshpande
157. Ayurved & Guda Bhransha
• Arogyavardhini + Triphala Guggulu – 3 each
BD with Abhayarishta 4 tsf BD with equal
quantity of water --- If Constipation + Erand
haritaki churna 1 tsf HS + If Krumi ,add Kapiladi
vati 3 tab HS
• Externally apply Shatadhauta Ghruta
• Anuvasan Basti – Karanj Tail or Shatavari tail
50 ml
• Dhupan with – Ud ,Dhup,Vekhand,Owa ,Shopa
2/6/2017 157Prof.Dr.R.R.Deshpande
158. Ayurved & Guda Bhransha
• If Ajjerna ,Aanah, Aatop – add Praval
panchamrut tab 3 BD with Pippalyadi kadha
or Panchakolasav 4 tsf with equal quantity of
water
• If Gudabhransha is due to Atisar –Give
Sanjeevani tab 3 BD with Kutarishta 4 tsf with
equal quanrity of water
2/6/2017 158Prof.Dr.R.R.Deshpande
159. Ayurved & Guda Bhransha
• Rasayan – to improve Mansa Samvanan (
Tone of muscle ) –
• Vishatinduk vati ( Kuchala or nux vomica)
-2 tab after breakfast with Balarishta 4
tsf with equal quantity of water &
Chukra tail Picchu at anal region at night
with Bandage
2/6/2017 159Prof.Dr.R.R.Deshpande
161. Ayurved &Parikartika( Fissure in Ano )
• Dosha – Vata prakop due to ruksha, khara,
sukshma gun ,Pitta prakop due to Ushna
,Tikshna gun
• Dhatu – Rasa Kshay,Rakta dushti ,Mansa
Kshay ; Mala – Purisha
• Chikitsa – Shaman, Vatanuloman, Vata
shaman ,Rakta prasadan, Pitta shaman
2/6/2017 161Prof.Dr.R.R.Deshpande
162. Ayurved & Parikartika(Fissure in Ano)
• Chikitsa – Praval pishti vati + Kamdudha – 3
tab each BD with Abhayarishta 4 tsf BD with
equal water
• If severe pain & burning – Tab Triphala
Guggulu + Tab Kaishor Guggulu – 3 tab each
BD & Mauktik bhasma 30 mg + Avipattikar
churna 3 gm HS
2/6/2017 162Prof.Dr.R.R.Deshpande
163. Ayurved & Parikartika(Fissure in Ano)
• If very hard stool – Chinchalavan tail 3 tsf BD
,before food
• Externally --- Avagaha sweda with Luke warn
Triphala + Shatavari + Arjun + Yastimadhu
decoction in the morning & Shatavari Tail or
Shatadhaut ghrut Pichu with Bandage or diaper at
night
• Pathya – soft diet ,eating black raisins & dry figs
• Apathya – Dry ,spicy ,irritating food
2/6/2017 163Prof.Dr.R.R.Deshpande
164. Bhagandar ( Fistula in Ano )
• Associated diseases – Krumi,
Malavrodha,
Parikartika,Arsha,Kushtha,Vran ,Nadi
vran
• Dosha – Piita dushti ,Kapha prakop
• Dhatu – Rasa or lasika ,Rakta dushti
,Mansa dushti
• Mala – Purisha ,Kleda
2/6/2017 164Prof.Dr.R.R.Deshpande
165. Bhagandar ( Fistula in Ano )
• Chikitsa – Malanuloman ,Rakta shodhan
,Vrana shodhan, Vran ropan ,Agni
vardhan, Kapha pitta shaman
• Triphala Guggulu + Arogyavardhini +
Praval pishti + Kamdudha –each 3 BD
with Mahamanjisthadi Kadha 4 tsf with
equal quantity of water
2/6/2017 165Prof.Dr.R.R.Deshpande
166. Bhagandar ( Fistula in Ano )
• If only oedema – Upanaha with
Takankhar + wheat dough
• Lasika strav – Upanah + apply Eladi tail or
vran shodhan tail
• If severe pain – Dhupan –with – Ud ,
Dhup, Vekhand ( Acoraus calamus) ,Owa
( Ajwain ) ,Shepa ( fennel)
2/6/2017 166Prof.Dr.R.R.Deshpande
167. Bhagandar ( Fistula in Ano )
• Best policy – Tatra Dhanvantariyanam
Adhikaraha – refer to surgeon for Kshar sutra
treatment ( Refer PPT of Ksharsutra by
Prof.Dr.R.R.deshpande on slideshare.com )
• Rasayan – Tab Thayostanin ( Ayurved
Rasashala ,Pune ) 3 in the morning with
Sarivadyasav 4 tsf with equal quantity of
water
2/6/2017 167Prof.Dr.R.R.Deshpande
168. Bhagandar ( Fistula in Ano )
• Pathya --- Soft diet ,Local Anorectal Hygiene
• Apathya – Spicy & irritating food ,Synthetic or
tight under garments ,Keeping late at night
,Alcohol ,Tobacco, Smoking,Non Veg food
,Prolonged sitting at one place ,sitting on very
hard surface ,Excess travelling on bike
2/6/2017 168Prof.Dr.R.R.Deshpande
170. Arsha ( Piles )
• Chikitsa – Vatanuloman ,Rakta shodhan,
Kaphagnha
• Shushkarsha – Tab Arogyavardhini ,Kankayan
guti ,Triphala guggulu – 3 tab each BD with
Abhayarishta 4 tsf with equal quantity of
water
• If Oedema – Apply Sarjaras malam
2/6/2017 170Prof.Dr.R.R.Deshpande
171. Arsha ( Piles )
• If Pain – Upanaha with dove of Jwar or
Dhupan with – Dhup,Ud,Vekhand,Owa or
Avagaha sweda with Triphala ,Dashamul
decoction
• Raktarsha – Tab Bolbaddha ras ,Praval pishti
,Kamdudha ras – each 3 tab BD with
Ashokarishta + Kutajarishta - 4 tsf each with
equal quantity water
2/6/2017 171Prof.Dr.R.R.Deshpande
172. Raktarsha Arsha ( Piles )
• If severe weakness due to bleeding –
• Mauktik Bhasma 50 mg + Nagkeshar
churna 500 mg + Tapyadi loha vati 2 tab
BD – with Lohasav 4 tsf with equal
quantity of water
• Dhupan is contraindicated
2/6/2017 172Prof.Dr.R.R.Deshpande
173. Arsha ( Piles )
• Pathya --- Soft diet ,Local Anorectal Hygiene
• Apathya – Spicy & irritating food ,Synthetic or
tight under garments ,Keeping late at night
Alcohol ,Tobacco, Smoking, Non Veg food
Prolonged sitting at one place ,sitting on very
hard surface ,Excess travelling on bike
2/6/2017 173Prof.Dr.R.R.Deshpande