Anorectal diseases

Anatomy
• The small intestine is a tubular structure that
extends from the pylorus to the cecum.
• Measures 4 to 6 meters.
• The small intestine consists of three segments lying in
series:
• Duodenum,
• Jejunum, and
• Ileum.

Duodenum
● Most proximal segment.
● Lies in the retroperitoneum immediately adjacent
to the head and inferior border of the body of the
pancreas.
● Demarcated from the stomach by the pylorus and
● From the jejunum by the ligament of Treitz
Jejunum and Ileum
● Lie within the peritoneal cavity
● Tethered to the retroperitoneum by a broad-based mesentery.
● No distinct anatomical landmark demarcates the jejunum from the
ileum; jejunoileal segment( proximal 40% - jejunum and the distal
60% - ileum.)
● The ileum is demarcated from the cecum by the ileocecal valve.

Plicae circulares or valvulae conniventes
● Internal mucosal folds of small intestine
● Visible upon gross inspection.
● On abdominal radiographs - help in the distinction
between small intestine and colon(which does not
contain them).
● More prominent in the proximal intestine
Peyer’s patches
● The lymphoid follicles, located in the ileum
● Prevents the growth of pathogenic bacteria
in the intestines.
Relative to the ileum, the jejunum has a
larger diameter, a thicker wall, more
prominent plicae circulares, a less fatty
mesentery, and longer vasa recta.

BLOOD SUPPLY:
● Duodenum - celiac and the superior mesenteric arteries.
● Distal duodenum, the jejunum, and the ileum - superior mesenteric artery
Venous drainage - Superior mesenteric vein.
Lymph drainage occurs through
● Mesenteric lymph nodes ? cisterna chyli ? thoracic duct ? left subclavian vein
● Lymphatic vessels coursing parallel to corresponding arteries.
● INNERVATION
● Parasympathetic - Vagus nerves.
● Sympathetic - Splanchnic nerves.

histology
• Serosa consists of a single layer of mesothelial cells and is a component of the visceral peritoneum
• Muscularis propria consists of an
• Outer, longitudinally oriented layer
• Inner, circularly-oriented layer of smooth muscle fibers.
• Located at the interface between these two layers are ganglion cells of the myenteric (Auerbach’s)
plexus.
• Submucosa consists of dense connective tissue and a heterogeneous population of cells, including leukocytes
and fibroblasts.
● Contains an extensive network of vascular and lymphatic vessels, nerve fibers, and ganglion cells of the
submucosal (Meissner’s) plexus.
• Mucosa is the innermost layer and it consists of three layers:
● Epithelium
● Lamina propria
● Muscularis mucosae
• Mucosa is organized into villi and crypts (crypts of Lieberkuhn).
• Villi are finger-like projections of epithelium and underlying lamina propria that contain blood and lymphatic
(lacteals) vessels that extend into the intestinal lumen.
• Intestinal, epithelial cellular proliferation is confined to the crypts, each of which carries 250 to 300 cells.

Developmental rotation of
the intestine.
A. During the fifth week of gestation, the developing
intestine herniates out of the coelomic cavity and
begins to undergo a counterclockwise rotation about
the axis of the superior mesenteric artery.
B and C. Intestinal rotation continues, as the
developing transverse colon passes anterior to the
developing duodenum.
D. Final positions of the small intestine and colon
resulting from a 270° counterclockwise rotation of
the developing intestine and its return into the
abdominal cavity

physiology
• Digestion and Absorption
● The intestinal epithelium is the interface through which
absorption and secretion occur.
● Solutes can traverse the epithelium by active or passive transport.
● Active transport occurs through transcellular pathways (through the
cell),
● Passive transport can occur through either transcellular or paracellular
pathways (between cells through the tight junctions).

Water and Electrolyte Absorption
and Secretion
● 8 to 9 L of fluid enter the small intestine daily.
● Most of this volume consists of salivary, gastric, biliary,
pancreatic, and intestinal secretions.
● The small intestine absorbs over 80% of this fluid, leaving
approximately 1.5 L that enters the colon.
• Gut epithelia have two pathways for water transport:
a. The paracellular route, which involves transport through
the spaces between cells,
b. The transcellular route, through apical and the
basolateral cell membranes, with most occurring
through the transcellular pathway.

Regulation of intestinal absorption and secretion
• Agents that stimulate absorption or
inhibit secretion of water
● Aldosterone
● Glucocorticoids
● Angiotensin
● Norepinephrine
● Epinephrine
● Dopamine
● Somatostatin
● Neuropeptide Y
● Peptide YY
● Enkephalin
• Agents that simulate secretion or inhibit
absorption of water
• Secretin
• Bradykinin
• Prostaglandins
• Acetylcholine
• Atrial natriuretic factor
• Vasopressin
• Vasoactive intestinal peptide
• Bombesin
• Substance P
• Serotonin
• Neurotensin
• Histamine

Carbohydrate Digestion and Absorption
• 45% of energy consumption
• Dietary carbohydrates, including starch and
the disaccharides (sucrose and lactose), must
undergo hydrolysis into constituent
monosaccharides (glucose, galactose, and
fructose) before being absorbed by the
intestinal epithelium.
• These hydrolytic reactions are catalyzed by
salivary and
pancreatic amylase and by enterocyte brush
border hydrolases.
• Most of these sugars are absorbed through the
epithelium via the transcellular route.

• Glucose and galactose are transported
through the enterocyte brush border
membrane via intestinal Na+glucose
cotransporter, SGLT1
• Fructose is transported by facilitated diffusion
via GLUT5 (a member of the facilitative glucose
transporter family).
• All three monosaccharides are extruded
through
the basolateral membrane by facilitated
diffusion using GLUT2 and five transporters.
• Extruded monosaccharides diffuse into venules
and ultimately enter the portal venous system

Protein Digestion and Absorption
• Ten percent to 15% of energy consumption.
• Protein digestion begins in the stomach with
action of pepsins.
• Digestion continues in the duodenum with the
actions of a variety of pancreatic peptidases.
• Dietary proteins must undergo hydrolysis
into constituent single amino acids and di-
and tripeptides before being absorbed by
the intestinal epithelium.
• These hydrolytic reactions are catalyzed by
pancreatic peptidases (e.g., trypsin) and by
enterocyte brush border peptidases.
• Enterokinase catalyze the conversion of
trypsinogen to active trypsin; trypsin in turn
activates itself and other proteases

Protein Digestion and Absorption
• Final products of intraluminal protein digestion are neutral and basic amino acids and peptides two to
six amino acids in length
• Additional digestion occurs through the actions of peptidases that exist in the enterocyte brush border
and cytoplasm.
• Epithelial absorption occurs for both single amino acids and di- or tripeptides via specific membrane-
bound transporters.
• Absorbed amino acids and peptides then enter the portal venous circulation.
• Glutamine - major source of energy for enterocytes.
• Active glutamine uptake into enterocytes occurs through both apical and basolateral transport
mechanisms

FAT DIGESTION AND ABSORPTION
• 40% of the average Western diet consists of
fat.
• Long-chain triglycerides, (95%of dietary fats)
must undergo lipolysis into constituent long-
chain fatty acids and monoglycerides before
being absorbed by the intestinal epithelium.
• These reactions are catalyzed by gastric
and pancreatic lipases.
• Bile acids act as detergents that help in
solubilization of the lipolysis by forming
mixed micelles.

FAT
DIGESTION
AND
ABSORPTION
• Most lipids are absorbed in the proximal jejunum, whereas bile
salts are absorbed in the distal ileum through an active process
• The products of lipolysis are transported in the form of mixed
micelles to enterocytes, where they are resynthesized into
triglycerides, which are then packaged in the form of chylomicrons
that are secreted into the intestinal lymph (chyle).
• Triglycerides composed of short- and medium-chain fatty acids are
absorbed by the intestinal epithelium directly, without undergoing
lipolysis, and are secreted into the portal venous circulation.

VITAMIN AND MINERAL ABORPTION
• Vitamin B12 (cobalamin) malabsorption can result from a variety of surgical manipulations.
• The vitamin is initially bound by saliva-derived R protein.
• In the duodenum, R protein is hydrolyzed by pancreatic enzymes, allowing free cobalamin to bind to gastric parietal cell-
derived intrinsic factor.
• The cobalamin-intrinsic factor complex can reach the terminal ileum, which expresses specific receptors for intrinsic factor.
• Gastric resection, Gastric bypass, and Ileal resection can each result in vitamin B12 insufficiency.
• water-soluble vitamins (ascorbic acid, folate, thiamine, riboflavin, pantothenic acid, and biotin). -specific carrier mediated
transport processes
• Fat-soluble vitamins (A, D, and E) - absorbed through passive diffusion.
• Vitamin K - absorbed through both passive diffusion and carrier- mediated uptake.
• Calcium is absorbed through transcellular transport(duodenum) and paracellular diffusion(small intestine).
• Abnormal calcium levels - gastric bypass patients.
• Iron and magnesium are each absorbed through both transcellular and paracellular routes.
• A divalent metal transporter capable of transporting Fe2+, Zn2+, Mn2+, Co2+, Cd2+, Cu2+, Ni2+, and Pb2+ that has been localized
to the intestinal brush border may account for at least a portion of the transcellular absorption of these ions

BARRIER AND IMMUNE FUNCTION
• Factors of epithelial defense - immunoglobulin A (IgA), mucins, and the relative
impermeability of the brush border membrane and tight junctions to macromolecules
and bacteria.
• Factors of intestinal mucosal defense - antimicrobial peptides (defensins).
• gut-associated lymphoid tissue (GALT), contains over 70% of the body’s immune cells.
• Peyer’s patches are macroscopic aggregates of B-cell follicles and intervening T-cell
areas found in the lamina propria of the small intestine, primarily the distal ileum.
• Overlying Peyer’s patches is a specialized epithelium containing microfold (M) cells
which transfer microbes to APC cells (dendritic cells)
• IgA - prevent the entry of microbes through the epithelium and promote excretion of
antigens or microbes that have already penetrated the laminal propria.

motility
• Myocytes of the intestinal muscle layers are electrically and mechanically coordinated in
the form of syncytia.
• Contractions of the muscularis propria - small-intestinal peristalsis.
● Contraction of the outer longitudinal muscle layer - bowel shortening;
● Contraction of the inner circular layer - luminal narrowing.
• Contractions of the muscularis mucosa contribute to mucosal or villus motility, but not to
peristalsis
• The fasting pattern or interdigestive motor cycle (IDMC)
consists of three phases.
● Phase 1 is characterized by motor quiescence,
● Phase 2 by disorganized pressure waves occurring at submaximal rates,
● Phase 3 by sustained pressure waves occurring at maximal rates.
• This pattern is hypothesized to expel residual debris and bacteria from the small
intestine.
• The median duration of the IDMC - 90 to 120 minutes.
• At any given time, different portions of the small intestine can be in different phases of the
IDMC
• .

motility
• Interstitial cells of Cajal
● located within the muscularis propria
● generate the electrical slow wave
● pacemaker role in setting the fundamental rhythmicity of small-
intestinal contractions.
• Frequency of the slow wave - 12 waves per minute in the duodenum to 7
waves per minute in the distal ileum.
• The enteric motor system (ENS) provides both inhibitory and
excitatory stimuli.

INTESTINAL ADAPTATION
• Postresection adaptation serves to compensate for the function of intestine that
has been resected.
• Jejunal resection is generally better tolerated, as ileum shows better capacity
to compensate.
• However, the magnitude of this response is limited.
• If enough small intestine is resected, a devastating condition known as the
short bowel syndrome results.

2. COMMON ETIOLOGIES OF SMALL BOWEL OBSTRUCTION
• Mechanical small bowel obstruction is the most frequently
encountered surgical disorder of the small intestine.
• Classified according to anatomical relationship to the
intestinal wall
● 1. intraluminal (e.g., foreign bodies, gallstones, or
meconium)
● 2. intramural (e.g., tumors, Crohn’s disease–associated
inflammatory strictures)
● 3. extrinsic (e.g., adhesions, hernias, or carcinomatosis)
• Intra-abdominal adhesions related to prior abdominal
surgery account for up to 75% of cases of small bowel
obstruction
• Cancer-related small bowel obstructions are commonly due
to extrinsic compression or invasion by advanced
malignancies arising in organs other than the small bowel;
few are due to primary small bowel tumors

3. PATHOPHYSIOLOGY
• With onset of obstruction, gas and fluid accumulate within the intestinal lumen proximal to the site of
obstruction.
• The intestinal activity increases to overcome the obstruction? colicky pain; diarrhea
• Most of the gas that accumulates originates from swallowed air, although some is produced
within the intestine.
• The fluid consists of swallowed liquids and gastrointestinal secretions (obstruction stimulates
intestinal epithelial water secretion).
• With ongoing gas and fluid accumulation, the bowel distends and intraluminal and intramural
pressures rise.
• The intestinal motility is eventually reduced with fewer contractions.
• With obstruction, the luminal flora of the small bowel, which is usually sterile, changes and a variety
of organisms have been cultured from the contents. Translocation of these bacteria to regional
lymph nodes may be seen

3. PATHOPHYSIOLOGY
• Strangulated bowel obstruction-
● If the intramural pressure becomes high enough, intestinal microvascular perfusion is impaired
leading to intestinal ischemia, and, ultimately, necrosis.
• Partial small bowel obstruction,
● only a portion of the intestinal lumen is occluded, allowing passage of some gas and fluid. Slow
progression. Development of strangulation is less likely.
• Closed loop obstruction -
● A particularly dangerous form of bowel obstruction in which a segment of intestine is obstructed
both proximally and distally (e.g., with volvulus). In such cases, the accumulating gas and fluid
cannot escape either proximally or distally from the obstructed segment, leading to a rapid rise in
luminal pressure and a rapid progression to strangulation.
• The intestinal activity increases to overcome the obstruction, accounting for the colicky pain and the
diarrhea that some experience even in the presence of complete bowel obstruction.

Endoscopy - ANOSCOPY
· Instrument used to examine the anal canal
· Measures approximately 8 cm in length
· Larger anoscope – anal procedures Rubber
band ligation
Inserted into the anal canal
Obturator is withdrawn, inspection is done and the anoscope withdrawn
Rotated 90 degrees and reinserted to allow visualization of all four
quadrants of the canal
If patient can’t tolerate DRE, anoscopy should not be attempted

CONTINENCE
• Branches of the pudendal nerve innervate both the
internal and external sphincter.
• The hemorrhoidal cushions may contribute to continence
by mechanically blocking the anal canal.
• Finally, liquid stools exacerbate abnormalities with
these anatomic and physiologic mechanisms, so a
formed stool contributes to maintaining continence.
• Thus, impaired continence may result from poor rectal
compliance, injury to the
• internal and/or external sphincter or puborectalis, or
neuropathy.

PROCTOSCOPY
 Rigid proctoscope – examination of rectum and distal sigmoid colon
· Ocassionally used to therapeutics
· 25 cm in length and in various diameters (15 or 19mm)
· Pediatric (11 mm)
· Suction is necessary for an adequate examination
· Transanal Endoscopic Microsurgery (TEM)
Much wider diameter
Can be used for excision of large polyps and tumors Transanal
Minimally Invasice Surgery (TAMIS)
Can achieve similar resections to TEM but does not utilize a
proctoscope and depends on insufflation

SIGMOIDOSCOPY AND COLONSCOPY
Video or fiberoptic sigmoidoscopy and colonoscopy
· Sigmoidoscopes measures 60cm in length
· Full depth may allow visualization until the splenic flexure
· Partial preparation with enemas is adequate
· Most patients can tolerate this without sedation
Colonoscopes measure 100-160cm in length can examine the entire colon and terminal ileum
· Complete bowel preparation is usually necessary
· Duration and discomfort usually requires conscious sedation
· Electrocautery should not be used in the absence of complete bowel preparation
Risk for explosion of intestinal methane or hydrogen gases
· Colonoscopes –single channel where snares, biopsy forceps or electrocautery can be passed
Suction and irrigation capability
Therapeutic colonoscopies possess two channels – simultaneous suction/irrigation and use of
snares, biopsy forceps and electrocautery
Capsule endoscopy:
 is an emerging technology that uses a small ingestible camera. After swallowing the camera, images of the mucosa of
the gastrointestinal tract are captured, transmitted by radiofrequency to a belt-held receiver,
Used to detect small bowel lesions
· Possibility of an acute obstruction led to Dissolvable capsule

IMAGING PLAIN X-RAYS and CONTRAST STUDIES
Plain x-rays (supine, upright and diaphragmatic views)
Detects free intra-abdominal air Bowel gas patterns – obstruction
Volvulus
· Obstructive symptoms
· Delineating fistulous tracts
· Diagnosing small perforations
· Anastomotic leaks
·Gastrografin cannot provide mucosal detail provided by barium, this water-soluble agent is recommended for
perforation or leak
· Double-contrast barium enema (followed by insufflation of air)
70-90% sensitive mass lesions greater than 1cm in diameter

COMPUTED TOMOGRAPHY
Detection of extraluminal disease
o Intra-abdominal abscesses
o Pericolic inflammation
o Staging colorectal carcinoma
Sensitivity in detecting hepatic metastases
o Extravasation of oral or rectal contrast
Perforation or anatomic leak
• Nonspecific findings Bowel wall thickening
Mesenteric stranding
Inflammatoy bowel disease
• Enteritis/colirtis
Ischemia
Standard CT Scan
Insensitive for the detection of intraluminal lesions

Virtual Colonoscopy
· Designed to overcome the limitations of conventional CT scanning
· Helical CT and 3D reconstruction to detect intraluminal colonic lesions
· Oral bowel preparation, oral and rectal contrast, colon insufflation may
maximize sensitivity
· 85-90% sensitivity and specificity in detecting 1cm or larger polyps
· Alternative for traditional colonoscopy
COMPUTED TOMOGRAPHY COLONOGRAPHY

MAGNETIC RESONANCE IMAGING
Evaluation of pelvic lesions
· More sensitive than CT in detecting bony involvement or pelvic
sidewall extention of rectal tumors
· Accurate in detecting extent of rectal cancer spread to adjacent
mesorectum
· Reliably predict difficulty in achieving radial margin clearance of a
rectal cance
· If radial margin is threatened, neoadjuvant chemoradiation is indicated
·Helpful in detection and delineation of complex fistulas in ano Endorectal coil
increases sensitivity
·

POSITRON EMISSION TOMOGRAPHY
 Imaging tissues with high levels of anaerobic glycolysis – malignant tumors
· F-fluorode-oxyglucose (FDG) is injected as a tracer
Metabolism of this molecule results in positron emission
Adjunct to CT scan in the staging of colorectal cancer
Useful in discriminating recurrent cancer from fibrosis
PET/CT
 Anatomic regions of high isotope accumulation (hot spots on PET)
 Increasingly used to diagnose recurrent and/or metastatic colorectal
cancer

SCINTIGRAPHY TO ASSESS
GASTROINTESTINAL BLEEDING
Technetium 99-tagged RBC scan
· Nuclear medicine that tests Tc-erythrocytes and dynamic images to
localize a bleeding source
· Patients actively bleeding at the time of imaging
· Normal distribution of Tc-erythrocytes in vasculature, liver, spleen, penile
circulation with mild uptake in kidneys and bladder
o Can interfere with localization in bowel segments near those
given structures
· Patients must be stable to tolerate imaging up to 4 hours with slow
bleeding rate of 0.05-2.0mL/min

SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT/CT)
 Radiolabeled RBCs are used
 Cross-sectional images provide a more specific
location of the bleeding source

ANGIOGRAPHY
Ocassionally used for detection of bleeding within the colon or small bowel
· Visualize hemorrhage
o Brisk bleeding (0.5-1.0mL/min)
· If extravasation of contrast identified, infusion of vasopression or
angiographic embolixation can be therapeutic
· If surgical resection required, angiographic catheter can be left in place
to assist in the identification of bleeding site intraoperatively
· CT and MRI angiography are also useful in assessing patency of
visceral vessels
· Technique uses 3D reconstruction to detect vascular lesions
· If there is an abnormality, traditional techniques may be used for further
definition of the problem

Primarily used in the evaluation of the depth of invasion of neoplastic lesions in the
rectum
· Normal rectum wall appears as a five-layer structure
such as this one
· Can reliably differentiate most benign polyp from invasive
tumors based on the integrity of the submucosal layer
· Can also differentiate superficial T1-T2 from deeper
T3-T4 tumors
· Useful in the evaluation of patients with incontinence,
constipation, rectal prolapse, obstructed defection and other functional disorders of
the pelvic floor
ENDORECTAL AND ENDOANAL ULTRASOUND

MANOMETRY
Placing a pressure-sensitive catheter in the lower rectum
· Catheter withdrawn through the anal canal and
pressures recorded
· Balloon is attached to the tip of the catheter
· The resting pressure in the anal canal reflects the function of the internal
anal sphincter (N= 40-80mmHg
above resting pressure)
· High pressure zone estimates lengh of the anal canal
(N=2.0-4.0cm)
· The rectoanal inhibitory reflex can be detected by
inflating a balloon in the distal rectum
o Absence of this reflex = Hirschsprung Disease

RECTAL
EVACUATION
STUDIES
Balloon expulsion test and video defecography
· Balloon expulsion - Patient’s ability to expel and intrarectal balloon
· Video defecography – more detailed assessment of defecation
o Barium paste is placed in the rectum and defecation is recorded
fluoroscopically
o Help diagnose
 Obstructed defecation from nonrelaxation of the puborectalis muscle
or anal sphincter dyssynergy
 Increased perineal descent
 Rectal prolapse
 Intussusception
 Rectocele
 Enterocele
o Addition of vaginal contrast and intraperitoneal contrast

Function of the pudendal nerves and recruitment of puborectalis muscle fibers
· Pudenda; nerve terminal motor latency measures peed of transmission of a nerve impulse
through distal pudendal nerve fibers (N=1.8-2.2ms)
o Prolonged latency = presence of neuropathy
· E M G recruitment assesses the contraction and relaxation of the
puborectalis muscles during attempted defecation
o Recruitment increases when a patient is instructed to squeeze
o Decreases when instructed to push
o Inappropriate recruitment is an indication of paradoxical
Contraction
Needle E M G has been used to map both the pudendal nerves and the anatomy of the internal and
external sphincters
· Painful and poorly tolerated by most patients
NEUROPHYSIOLOGY

HISTORY FINDINGS
 change in bowel habits
 rectal bleeding
 Swollen lymph nodes in anal or groin areas.
 Abdominal pain, bloating,
 Anorectal Pain: most often secondary to an anal fissure, perirectal
abscess and/or fistula, or a thrombosed hemorrhoid.
 Constipation and Obstructed Defecation.
 Incontinence
 Abnormal discharge from the anus.
 Rectal tumors cause bleeding

QUESTIONS ASKED IN HISTORY:
 If patients have had prior intestinal surgery, to understand the resultant
gastrointestinal anatomy, as patient with anorectal surgeries have
abdomial complaints.
 Obstetrical history in women is essential to detect occult pelvic floor
and/or anal sphincter damage.
 Family history of colorectal disease, especially inflammatory bowel disease,
polyps, and colorectal cancer, is also asked.
 history of medications is also asked

5. DESCRIBE THE INDICATION OF ENDOSCOPY
 Anascopy
 Proctoscopy
 Sigmoidoscopy and/or colonoscopy.
 Flexible Sigmoidoscopy
 Colonoscopy

ALARMING INDICATION
•Anoscopy -Painless, bright red rectal bleeding with bowel
movements is often secondary to a friable internal hemorrhoid
that is easily detected by anoscopy.
•In the absence of a painful, obvious fissure, any patient with rectal
bleeding should undergo a careful digital rectal examination,
anoscopy, and proctosigmoidoscopy.
•Failure to diagnose a source in the distal anorectum should
prompt
colonoscopy

ANOSCOPY
• Anoscopy.
•The anoscope is a useful instrument for examination of the anal canal.
Anoscopes are made in a variety of sizes and measure approximately 8 cm in
length.
•A larger anoscope provides better exposure for anal procedures such as
rubber band ligation or sclerotherapy of hemorrhoids.
•The anoscope, with obturator in place, should be adequately lubricated
and gently inserted into the anal canal.
•The obturator is withdrawn, inspection of the visualized anal canal is
done, and the anoscope should then be withdrawn.
•It is rotated 90° and reinserted to allow visualization of all four quadrants of
the canal. If the patient complains of severe perianal pain and cannot
tolerate a digital rectal examination, anoscopy should not be attempted
without anesthesia

INDICATION -IN PATIENTS
 •If the patient complains of severe perianal pain and cannot
tolerate a digital rectal examination, anoscopy should not be
attempted without anesthesia

PROCTOSCOPY
•Proctoscopy. The rigid proctoscope is useful for examination
•of the rectum and distal sigmoid colon and is occasionally used
therapeutically.
•The standard proctoscope is 25 cm in length and available in various
diameters. Most often, a 15- or 19-mm diameter proctoscope is used for
diagnostic examinations.
•The large (25-mm diameter) proctoscope is useful for procedures such as
polypectomy, electrocoagulation, or detorsion of a sigmoid volvulus.
•A smaller “pediatric” proctoscope (11-mm diameter) is better tolerated by
patients with anal stricture.
• Suction is necessary for an adequate proctoscopic examination.

SIGMOIDOSCOPY AND COLONOSCOPY. -INDICATION
 •Sigmoidoscopy and/or colonoscopy performed by an experienced
endoscopist can assist in the diagnosis of ischemic colitis,
infectious colitis, and inflammatory bowel disease.

FLEXIBLE SIGMOIDOSCOPY AND COLONOSCOPY
•In this procedure Video or fiberoptic flexible sigmoidoscopy and
colonoscopy provide excellent visualization of the colon and rectum.
•Sigmoidoscopes measure 60 cm in length.
•Full depth of insertion may allow visualization as high as the
splenic flexure, although the mobility and redundancy of the
sigmoid colon often limit the extent of the examination.
•Partial preparation with enemas is usually adequate for
sigmoidoscopy, and most patients can tolerate this procedure
without sedation

1) FLEXIBLE SIGMOIDOSCOPY
•Flexible Sigmoidoscopy.
•Screening by flexible sigmoidoscopy every 5 years may lead to a
60% to 70% reduction in mortality from colorectal cancer, chiefly by
identifying high-risk individuals with adenomas.
•It is important to recognize that lesions in the proximal colon
cannot be identified, and for this reason, flexible sigmoidoscopy has
often been paired with air-contrast barium enema to detect
transverse and right colon lesions.

1) FLEXIBLE SIGMOIDOSCOPY
 INDICATIONS
 Patients found to have a polyp, cancer, or other lesion on
flexible sigmoidoscopy will require colonoscopy.

ALARMING INDICATIONS (COLONSCOPY)
•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

COLONSCOPY
•Colonoscopy
•Colonoscopy is currently the most accurate and most complete
method for
examining the large bowel.
•This procedure is highly sensitive for detecting even small polyps
(<1 cm) and allows biopsy, polypectomy, control of hemorrhage,
and dilation of strictures.
•However, colonoscopy does require mechanical bowel preparation,
and the discomfort associated with the procedure requires conscious
sedation in most patients.
•Colonoscopy is also considerably more expensive than other
screening
modalities and requires a well-trained endoscopist.
•The risk of a major complication after colonoscopy (perforation and
hemorrhage) is extremely low (0.2%–0.3%). Nevertheless, deaths have
been reported.

COLONSCOPY
•Colonoscopes measure 100 to 160 cm in length and are capable of examining the entire
colon and terminal ileum.
•A complete oral bowel preparation is usually necessary for colonoscopy, and the
duration and discomfort of the procedure usually require conscious sedation.
•Both sigmoidoscopy and colonoscopy can be used diagnostically and therapeutically.
•Electrocautery should generally not be used in the absence of a complete bowel
preparation because of the risk of explosion of intestinal methane or hydrogen gases.
•Diagnostic colonoscopes possess a single channel through which instruments such as
snares, biopsy forceps, or electrocautery can be passed; this channel also provides
suction and irrigation capability.
•Therapeutic colonoscopes possess two channels to allow simultaneous suction/irrigation
and the use of snares, biopsy forceps, or electrocautery.

INDICATION
•If the patient is hemodynamically stable, a rapid bowel preparation
(over 4–6 hours) can be performed to allow colonoscopy.
•Colonoscopy may identify the cause of the bleeding, and cautery or injection of
epinephrine into the bleeding site may be used to control hemorrhage
•Intraoperative colonoscopy and/or enteroscopy may assist in localizing bleeding.
•If colectomy is required, a segmental resection is preferred if the
bleeding source can be localized.

AIR CONTRAST BARIUM ENEMA
•Air-Contrast Barium Enema.
•Air-contrast barium enema is also highly sensitive for detecting polyps
greater than 1 cm in diameter (90% sensitivity).
• Accuracy is greatest in the proximal colon but may be compromised
in the sigmoid colon if there is significant diverticulosis.
•The major disadvantages of barium enema are the need for mechanical bowel
preparation and the requirement for colonoscopy if a lesion is discovered

HEMORRHOIDS
 Hemorrhoids are 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.
 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.
 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.
 A skin tag is redundant fibrotic skin at the anal verge,often persisting as the residua of a
thrombosed external hemorrhoid
 External hemorrhoids and skin tags may cause itching
and difficulty with hygiene if they are large. Treatment of externalhemorrhoids and skin tags is only
indicated for symptomatic relief.

HEMORRHOIDS
 Internal hemorrhoids are located proximal to the dentate line and covered by insensate anorectal mucosa.
 Internal hemorrhoids may prolapse or bleed, but they rarely become painful unless they develop thrombosis and necrosis
(usually related to severe prolapse, incarceration, and/or strangulation).
 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
 Combined internal and external hemorrhoids straddlethe dentate line and have characteristics of both internal and external
hemorrhoids.
 Hemorrhoidectomy is often required for large, symptomatic, combined hemorrhoids. Postpartumhemorrhoids result from
straining during labor, which results in edema, thrombosis, and/or strangulation.
 Hemorrhoidectomy is often the treatment of choice, especially if the patient has had chronic hemorrhoidal symptoms.

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.
 Associated pruritus often may improve with improved hygiene.
Rubber Band Ligation Persistent bleeding from first-,
second-,
and selected third-degree hemorrhoids may be treated by
 rubber band ligation.
 Mucosa located 1 to 2 cm proximal to the dentate line
is grasped and pulled into a rubber band applier.
 After firingthe ligator, the rubber band strangulates the underlying tissue,causing
scarring and preventing further bleeding or prolapse

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.
 Associated pruritus often may improve with
improved hygiene.
Rubber Band Ligation Persistent bleeding from first-,
second-,
and selected third-degree hemorrhoids may be treated
by
 rubber band ligation.
 Mucosa located 1 to 2 cm proximal to the dentate line
is grasped and pulled into a rubber band applier.
 After firingthe ligator, the rubber band strangulates
the underlying tissue,causing scarring and
preventing further bleeding or prolapse
Rubber band ligation of
internal hemorrhoids. The
mucosa just proximal to the
internal hemorrhoids is
banded.

TREATMENT
Infrared Photocoagulation Infrared photocoagulation is 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. 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.

Infrared Photocoagulation Infrared photocoagulation is 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. 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.
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.
Excision of Thrombosed External Hemorrhoids The thrombosis can be effectively treated with
anelliptical excision performed in the office under local anesthesia.
 Because the clot is usually loculated, simple incision and
drainage is rarely effective.
 After 72 hours, the clot begins to resorb, and the pain resolves spontaneously.

Operative Hemorrhoidectomy:
 All are based on decreasing blood flow to the hemorrhoidal plexuses and excising redundant anoderm
and mucosa.
Closed Submucosal Hemorrhoidectomy:Theprocedure may be performed in the prone or lithotomy
position
under local, regional, or general anesthesia.
 The anal canal is examined and an anal speculum inserted.
 The hemorrhoid cushions and associated redundant mucosa are identified and excised using an elliptical
incision starting just distal to the anal verge and extending proximally to the anorectal ring
 The apex of the hemorrhoidal plexus is then ligated and the
hemorrhoid excised.
 The wound is then closed with a running absorbable suture
Technique of closed submucosal hemorrhoidectomy.
A. The patient is iNprone jackknife position
.B. A Fansler anoscope is used for
exposure
C.A narrow ellipse of anoderm is excised
D.A submucosal dissection of the hemorrhoidal plexus from the
underlying anal sphincter is performed.
E.Redundant mucosa is anchored to the proximal anal canal, and the
wound is closed with a running absorbable suture.
F.Additional quadrants are excised to complete the procedure.

OPEN HEMORRHOIDECTOMY:
This technique, often called the Milligan and Morgan
hemorrhoidectomy
Follows the same principles of excision
But the wounds are left open and allowed to heal by secondary intention
WHITEHEAD’S HEMORRHOIDECTOMY
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.

STAPLED HEMORHOIDECTOMY:
 Suited for patients with second- and third-degree haemorrhoids
 Out -patient procedure uses a stapling device
 Mucosa and submucosa, are generated by the PPH stapler
 Provides relief for internal hemorrhoids
 By removing redundant hemorrhoidal tissue, ligating the venules
feeding the hemorrhoidal plexus and fixing redundant mucosa proximal
to the dentate line.

DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION:
 Also called trans-anal hemorrhoidal dearterialization
 Another recent approach to treating symptomatic hemorrhoids is
 Doppler-guided hemorrhoidal artery ligation
 In this procedure, a Doppler probe is used to identify the artery or
arteries feeding the hemorrhoidal plexus.
 These vessels are then ligated.
B. 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.

DOPPLER-GUIDED HEMORRHOIDAL ARTERY LIGATION:
 Also called trans-anal hemorrhoidal dearterialization
 Another recent approach to treating symptomatic hemorrhoids is
 Doppler-guided hemorrhoidal artery ligation
 In this procedure, a Doppler probe is used to identify the artery or
arteries feeding the hemorrhoidal plexus.
 These vessels are then ligated.

B. 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.
 Characteristic symptoms include tearing pain with defecation and hematochezia (usually described as blood on the toilet
paper). Patients may also complain of a sensation of intense and painful anal spasm lasting for several hours after a bowel
movement.
 On physical examination, the fissure can often be seen in the anoderm by gently separating the buttocks.
 An acute fissure is a superficial tear of the distal anoderm
and almost always heals with medical management.
 Chronic fissures develop ulceration and heaped-up edges with the white fibers of the internal anal sphincter visible at the
base of the ulcer.
 There often is an associated external skin tag and/or a
hypertrophied anal papilla internally.
 These fissures are more challenging to treat and may require surgery

 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.
 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.
 Lateral internal sphincterotomy is the procedure of choice.
 The aim of this procedure is to decrease spasm of the internal sphincter by dividing
a portion of the muscle. Approximately 30% of the internal sphincter fibers are
divided laterally by using either an open or closed. technique

 Relevant Anatomy : The majority of anorectal suppurative disease results from infections
of the anal glands (cryptoglandular infection) found in the intersphincteric plane.
 Their ducts traverse the internal sphincter and empty into the anal crypts at the level of
the dentate line. Infection of an anal gland results in the formation of an abscess that
enlarges and spreads along one of several planes in the perianal and perirectal spaces.
 The perianal space surrounds the anus and laterally becomes continuous with the fat of
the buttocks.
 The intersphincteric space separates the internal and external anal sphincters.
 The ischiorectal space (ischiorectal fossa) is located lateral and posterior to the anus and
is bounded medially by the external sphincter, laterally by the ischium, superiorly by the
levator ani, and inferiorly by the transverse septum.
 The two ischiorectal spaces connect posteriorly above the anococcygeal ligament but
below the levator ani muscle, forming the deep postanal space.
 The supralevator spaces lie above the levator ani on either side of the rectum and
communicate posteriorly
ANORECTAL ABSCESS

 A 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
 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
 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).
 atypical presentations may require imaging studies such as CT or MRI to fully delineate the anatomy of the abscess.
ANORECTAL ABSCESS

 Anorectal abscesses should be treated by drainage.
 Most perianal abscesses can be drained under local anesthesia in the office, clinic, or
emergency department. Larger, more complicated abscesses may require drainage in the
operating room.
 An ischiorectal abscess causes diffuse swelling in the ischiorectal fossa that may involve one
or both sides, forming a “horseshoe” abscess.. Horseshoe abscesses require drainage of the
deep postanal space and often require counterincisions over one or both ischiorectal spaces.
 an intersphincteric abscess can be drained through a limited, usually posterior, internal
sphincterotomy.
ANORECTAL ABSCESS

 Proctitis is inflammation of the lining of the rectum. The rectum is a muscular tube that's
connected to the end of your colon. Stool passes through the rectum on its way out of the body.
 Proctitis can cause rectal pain, diarrhea, bleeding and discharge, as well as the continuous
feeling that you need to have a bowel movement. Proctitis symptoms can be short-lived, or
they can become chronic.
 Proctitis is common in people who have inflammatory bowel disease (Crohn's disease or
ulcerative colitis). Sexually transmitted infections are another frequent cause. Proctitis also can
be a side effect of radiation therapy for certain cancers.
PROCTITIS

 Symptoms
 Proctitis signs and symptoms may include:
 A frequent or continuous feeling that you need to have a bowel movement
 Rectal bleeding
 Passing mucus through your rectum
 Rectal pain
 Pain on the left side of your abdomen
 A feeling of fullness in your rectum
 Diarrhea
 Pain with bowel movements
PROCTITIS

Causes:
 Several diseases and conditions can cause inflammation of the rectal lining. They include:
 Inflammatory bowel disease. About 30% of people with inflammatory bowel disease (Crohn's
disease or ulcerative colitis) have inflammation of the rectum.
 Infections. Sexually transmitted infections, spread particularly by people who engage in anal
intercourse, can result in proctitis. Sexually transmitted infections that can cause proctitis
include gonorrhea, genital herpes and chlamydia. Infections associated with foodborne illness,
such as salmonella, shigella and campylobacter infections, also can cause proctitis.
 Radiation therapy for cancer. Radiation therapy directed at your rectum or nearby areas, such
as the prostate, can cause rectal inflammation. Radiation proctitis can begin during radiation
treatment and last for a few months after treatment. Or it can occur years after treatment.
PROCTITIS

 Antibiotics. Sometimes antibiotics used to treat an infection can kill helpful bacteria in the
bowels, allowing the harmful Clostridium difficile bacteria to grow in the rectum.
 Diversion proctitis. Proctitis can occur in people following some types of colon surgery in which
the passage of stool is diverted from the rectum to a surgically created opening (stoma).
 Food protein-induced proctitis. This can occur in infants who drink either cow's milk- or soy-
based formula. Infants breast-fed by mothers who eat dairy products also may develop
proctitis.
 Eosinophilic proctitis. This condition occurs when a type of white blood cell (eosinophil) builds
up in the lining of the rectum. Eosinophilic proctitis affects only children younger than 2.
PROCTITIS

Risk factors:
 Unsafe sex. Practices that increase your risk of a sexually transmitted infection (STI) can increase your
risk of proctitis. Your risk of contracting an STI increases if you have multiple sex partners, don't use
condoms and have sex with a partner who has an STI.
 Inflammatory bowel diseases. Having an inflammatory bowel disease (Crohn's disease or
ulcerative colitis ) increases your risk of proctitis.
 Radiation therapy for cancer. Radiation therapy directed at or near your rectum (such as for
rectal, ovarian or prostate cancer) increases your risk of proctitis.
PROCTITIS

Complications:
 Anemia. Chronic bleeding from your rectum can cause anemia. With anemia, you don't have enough
red blood cells to carry adequate oxygen to your tissues. Anemia causes you to feel tired, and you
may also experience dizziness, shortness of breath, headache, pale skin and irritability.
•Ulcers. Chronic inflammation in the rectum can lead to open sores (ulcers) on the inside lining of the
rectum.
•Fistulas. Sometimes ulcers extend completely through the intestinal wall, creating a fistula, an
abnormal connection that can occur between different parts of your intestine, between your intestine
and skin, or between your intestine and other organs, such as the bladder and vagina.
PROCTITIS

 Drainage of an anorectal abscess results in cure for about 50% of patients
 The remaining 50% develop a persistent fistula in ano.
 originates in the infected crypt (internal opening) and tracks to the external opening
• predicted by the anatomy of the previous abscess.
 majority of fistulas are cryptoglandular in origin, trauma, Crohn’s disease, malignancy,
radiation, or unusual infections (tuberculosis, actinomycosis, and chlamydia) may also produce
fistulas.
FISTULA IN ANO

 Patients present with persistent drainage from the
internal and/or external openings
 Goodsall’s rule can be used as a guide in determining the
location of the internal opening
 fistulas with an external opening anteriorly connect to
the internal opening by a short, radial tract.
 Fistulas with an external opening posteriorly track in a
curvilinear fashion to the posterior midline.
 exceptions to this rule often occur if an anterior external
opening is greater than 3 cm from the anal margin.
DIAGNOSIS

 intersphincteric fistula tracks through the distal internal
sphincter and intersphincteric space to an external
opening near the anal verge
 A transsphincteric fistula often results from an ischiorectal
abscess and extends through both the internal and
external sphincters
 A suprasphincteric fistula originates in the inter-
sphincteric plane and tracks up and around the entire
external sphincter
 An extrasphincteric fistula originates in the rectal wall and
tracks around both sphincters to exit laterally, usually in
the ischiorectal fossa
DIAGNOSIS

 goal of treatment of fistula in ano is eradication of sepsis
without sacrificing
continence
 surgical treatment is dictated by the location of the
internal and external openings and the course of the
fistula.
 exter-
 external opening is usually visible as a red elevation of
granulation tissue with
or without concurrent drainage
 Injection of hydrogen peroxide or dilute e methylene blue
may be helpful. Care must be taken to avoid creating an
artificial internal opening (thus often converting a simple
fistula into a complex fistula).
 Simple intersphincteric fistulas can often be treated by
fistulotomy (opening the
fistulous tract), curettage, and healing by secondary intention
 Advancement flaps (VY) with or without sphincterotomy treat
chronic fissures.
TREATMENT

 Human Papillomavirus HPV causes condyloma acuminate
(anogenital warts) and is associated with squamous
intraepithelial lesions and squamous cell carcinoma.
 Condylomas occur in the perianal area or in the
squamous epithelium of the anal canal.
 Occasionally, the mucosa of the lower rectum may be
affected. There are approximately 30 serotypes of HPV.
 As previously mentioned, HPV types 16 and 18, in particular,
appear to predispose to malignancy and often cause flat
dysplasia in skin unaffected by warts.
 In contrast, HPV types 6 and 11 commonly cause warts, but do
not appear to cause malignant degeneration.
ANAL CONDYLOMA

 Treatment of anal condyloma depends on the location and extent of disease. Small warts on the
perianal skin and distal anal canal may be treated in the office with topical application of
bichloracetic acid or podophyllin.
 Although 60% to 80% of patients will respond to these agents, recurrence and reinfection are
common. Imiquimod (Aldara) is an immunomodulator that was recently introduced for topical
treatment of several viral infections, including anogenital condyloma.
 100 Initial reports suggest that this agent is highly effective in treating
condyloma located on the perianal skin and distal anal canal.
 Larger and/ or more numerous warts require excision and/or fulguration in the operating room.
 Excised warts should be sent for pathologic examination to rule out dysplasia or malignancy.
 It is important to note that prior use of podophyllin may induce histologic
changes that mimic dysplasia.
 The recent introduction of a vaccine against HPV holds promise for preventing anogenital
condylomas.
TREATMENT

 Pilonidal disease (cyst, infection) consists of a hair-containing sinus or abscess occurring in the
intergluteal cleft.
 The etiology is unknown, it is speculated that the cleft creates a suction that draws hair into the midline pits
when a patient sits. These ingrown hairs may then become infected and present acutely as an abscess in
the sacrococcygeal region.
 Once an acute episode has resolved, recurrence is common.
 An acute abscess should be incised and drained as soon as the diagnosis is made. Because these
abscesses are usually very superficial, this procedure can often be performed in the office, clinic, or
emergency department under local anesthetic. Because midline wounds in the region heal poorly, some
surgeons recommend using an incision lateral to the intergluteal cleft.
PILONIDAL DISEASE

 A number of procedures have been proposed to treat a chronic pilonidal sinus. The simplest method
involves unroofing the tract, curetting the base, and marsupializing the wound.
 The wound must then be kept clean and free of hair until healing is complete (often requiring weekly office
visits for wound care). Alternatively, a small lateral incision can be created and the pit excised.
 This method is effective for most primary pilonidal sinuses. In general, extensive resection should be
avoided. Complex and/or recurrent sinus tracts may require more extensive resection and closure with a Z-
plasty, advancement flap, or rotational flap.
PILONIDAL DISEASE

 Drainage of an anorectal abscess results in cure for about 50% of patients. The remaining 50% develop a
persistent fistula in ano.
 The fistula usually originates in the infected crypt (internal opening) and tracks to the external opening,
usually the site of prior drainage.
 While the majority of fistulas are cryptoglandular in origin, trauma, Crohn’s disease, malignancy, radiation,
or unusual infections (tuberculosis, actinomycosis, and chlamydia) may also produce fistulas. A complex,
recurrent, or nonhealing fistula should raise the suspicion of one of these diagnoses.
FISTULA IN ANO

 Patients present with persistent drainage from the
internal and/or external openings. An indurated tract
is often palpable. Although the external opening is
often easily identifiable, identification of the internal
opening may be more challenging.
 Goodsall’s rule can be used as a guide in
determining the location of the internal opening.
 In general, fistulas with an external opening
anteriorly connect to the internal opening by a short,
radial tract. Fistulas with an external opening
posteriorly track in a curvilinear fashion to the
posterior midline.
 However, exceptions to this rule often occur if an
anterior external opening is greater than 3 cm from
the anal margin.Such fistulas usually track to the
posterior midline.
DIAGNOSIS

 Fistulas are categorized based on their relationship to the anal sphincter complex,
and treatment options are based on these classifications.
 An intersphincteric fistula tracks through the distal internal sphincter and intersphincteric space
to an external opening near the anal verge.
 A transsphincteric fistula often results from an ischiorectal abscess and extends
through both the internal and external sphincters.
 A suprasphincteric fistula originates in the intersphincteric plane and tracks up and around the entire
external sphincter.
 An extrasphincteric fistula originates in the rectal wall and tracks around both
sphincters to exit laterally,usually in the ischiorectal fossa.
DIAGNOSIS

 The goal of treatment of fistula in ano is eradication of sepsis without sacrificing continence.
 The external opening is usually visible as a red elevation of granulation tissue with or without concurrent drainage. The
internal opening may be more difficult to identify. Injection of hydrogen peroxide or dilute methylene blue may be
helpful.
 Care must be taken to avoid creating an artificial internal opening (thus often converting a simple fistula
into a complex fistula).
 Simple intersphincteric fistulas can often be treated by fistulotomy, curettage, and healing by secondary intention.
 “Horseshoe” fistulas usually have an internal opening in the posterior midline and extend anteriorly and
laterally to one or both ischiorectal spaces by way of the deep postanal space.
 Treatment of a transsphincteric fistula depends on its location in the sphincter complex.
 Fistulas that include less than 30% of the sphincter muscles can often be treated by sphincterotomy without significant
risk of major incontinence.
 High transsphincteric fistulas, which encircle a greater amount of muscle, are more safely treated by initial placement of a
seton. Similarly, suprasphincteric fistulas are usually treated with seton placement.
TREATMENT

The four major categories of fistula in ano (left
side of drawings) and the usual operative
procedure to correct the fistula (right side of
drawings).
A.Intersphincteric fistula with simple low tract.
B.Uncomplicated transsphincteric fistula.
C.Uncomplicated suprasphincteric fistula.
D.Extrasphincteric fistula secondary to anal
fistula.
TREATMENT

 Extrasphincteric fistulas are rare, and treatment depends on both the anatomy
of the fistula and its etiology.
 In general, the portion of the fistula outside the sphincter should be opened and
drained. A primary tract at the level of the dentate line may also be opened if
present. Complex fistulas with multiple tracts may require numerous procedures to
control sepsis and facilitate healing. Liberal use of drains and setons is helpful.
 Failure to heal may ultimately require fecal diversion.
 Complex and/or nonhealing fistulas may result from Crohn’s disease, malignancy,
radiation proctitis, or unusual infection. Proctoscopy should be performed in all cases
of complex and/or nonhealing fistulas.
TREATMENT

 Biopsies of the fistula tract should be taken to rule out malignancy. A seton is a
drain placed through a fistula to maintain drainage and/or induce fibrosis.
 Higher fistulas may be treated by an endorectal advancement flap. Fibrin glue and a
variety of collagen-based plugs also have been used to treat persistent fistulas with
variable results.
 Ligation of the intersphincteric fistula tract (LIFT) procedure id done .In this
procedure, the fistula is identified in the intersphincteric plane (usually by placement
of a lacrimal probe), divided, and the two ends ligated. Early reports have shown
success with this technique, but long-term outcome is not yet known
TREATMENT

 Cancers of the anal canal are uncommon and account for approximately 2% of all
colorectal malignancies.
 Neoplasms of the anal canal have traditionally been divided into those affecting the
anal margin (distal to the dentate line) and those affecting the anal canal (proximal
to the dentate line) based on lymphatic drainage patterns.
 Lymphatics from the anal canal proximal to the dentate line drain cephalad via the
superior rectal lymphatics to the inferior mesenteric nodes and laterally along both
the middle rectal vessels and inferior rectal vessels through the ischiorectal fossa to
the internal iliac nodes.
 Lymph from the anal canal distal to the dentate line usually drains to the inguinal
nodes. It can also drain to the superior rectal lymph nodes or along the inferior rectal
lymphatics to the ischiorectal fossa if primary drainage routes are blocked with tumor.
 A more clinically useful classification divides anal lesions into those that are perianal
(can be completely visualized with gentle eversion of the buttocks) and those that are
intra-anal (cannot be completely visualized with gentle eversion of the buttocks).
ANAL CANCER

 Anal intraepithelial neoplasia (AIN), Bowen’s disease, and carcinoma in situ all refer to
human papillomavirus (HPV)–induced dysplasia.
 Highgrade squamous intraepithelial lesions (HSIL) include highand intermediate-
grade
dysplasia, AINII and AINIII, Bowen’s disease, and carcinoma in situ. Low-grade
squamous intraepithelial lesions (LSIL) includes low-grade dysplasia and AINI.
Recently, the terms High- grade AIN (HGAIN; AINIII) and lowgrade AIN (LGAIN; AIN
I/II) have been suggested.
 Both high- and low-grade lesions are associated with infection with HPV, especially
types 16 and 18.
 High-grade lesions are precursors to invasive squamous cell carcinoma
(epidermoid carcinoma) and may appear as a plaque or may only be apparent
with high-resolution anoscopy and application of acetic acid and/or Lugol’s
iodine solution.
 The incidence of both squamous intraepithelial lesions and epidermoid carcinoma of
the anus has increased dramatically among human immunodeficiency virus (HIV)–
positive men who have sex with men. This increase is thought to result from
increased rates of HPV infection along with HIV-induced immunosuppression.
Squamous Intraepithelial Lesions

 Treatment of high-grade dysplasia is ablation. Because of a high recurrence
and/or reinfection rate, these patients require close surveillance.
 High-risk patients should be followed with frequent anal Papanicolaou (Pap)
smears every 3 to 6 months. An abnormal Pap smear should be followed by an
examination under anesthesia and anal mapping using highresolution anoscopy.
 High-resolution anoscopy shows areas with abnormal telangiectasias that are
consistent with highgrade dysplasia. Rarely, extensive disease may require resection
with flap closure.
 Medical therapy for HPV has also been proposed. Topical immunomodulators such
as imiquimod (Aldara) have been shown to induce regression in some series.
 151 Topical 5-fluorouracil has also been used in this setting. Finally, the introduction of
a
vaccine against HPV may help decrease the incidence of this disease in the future.
Squamous Intraepithelial Lesions

 Epidermoid carcinoma of the anus includes squamous cell carcinoma, cloacogenic
carcinoma, transitional carcinoma, and basaloid carcinoma. The clinical behavior
and natural history of these tumors are similar.
 It is a slow-growing tumor and usually presents as an intra-anal or perianal mass. Pain
and bleeding may be present.
 Perianal epidermoid carcinoma may be treated in a similar fashion as squamous cell
carcinoma of the skin in other locations because wide local excision can usually be
achieved without resecting the anal sphincter.
 Intra-anal epidermoid carcinoma cannot be excised locally, and first-line therapy
relies on chemotherapy and radiation (the Nigro protocol: 5-fluorouracil, mitomycin C,
and 30 Gy of external beam radiation).
 Metastasis to inguinal lymph nodes is a poor prognostic sign.
Epidermoid Carcinoma

 Verrucous carcinoma is a locally aggressive form of condyloma acuminata. Although these lesions do
not metastasize, they can cause extensive local tissue destruction and may be grossly
indistinguishable from epidermoid carcinoma.
 Wide local excision is the treatment of choice when possible, but radical resection may sometimes
be required.
 Topical immunomodulators such as imiquimod (Aldara) may shrink some tumors, but they are almost
never curative.Very large lesions may respond to external beam radiation, but resection is almost
always required.
Basal Cell Carcinoma.
 It is rare and resembles basal cell carcinoma elsewhere on the skin
 This is a slowgrowintumor that rarely metastasizes.
 Wide local excision is the treatment of choice, but recurrence occurs in up to 30% of patients.
Radical resection and/or radiation therapy may be required for large lesions
Verrucous Carcinoma (Buschke-Lowenstein Tumor, Giant
Condyloma Acuminata)

 Adenocarcinoma of the anus is extremely rare and usually represents downward spread of a
low rectal.
 It may occasionally arise from the anal glands or may develop in a chronic fistula.
 Radical resection, usually after neoadjuvant chemoradiation, is usually required.
 Extramammary perianal Paget’s disease is adenocarcinoma in situ arising from the apocrine glands of
the perianal area. The lesion is typically plaque-like and may be indistinguishable from high-grade
intraepithelial lesions
 Characteristic Paget’s cells are seen histologically. These tumors are often associated with a
synchronous gastrointestinal adenocarcinoma, so a complete evaluation of the intestinal tract should be
performed.
 Wide local excision is usually adequate treatment forperianal Paget’s disease.
Adenocarcinoma

 Anorectal melanoma is rare, comprising less than 1% of all anorectal malignancies and 1% to 2% of
melanomas. Diagnosis is often delayed, and symptoms are attributed to hemorrhoidal disease.
 Despite many advances in the treatment of cutaneous melanoma, prognosis for patients with
anorectal disease remains poor. Overall 5-year survival is less than 10%, and many patients present
with systemic metastasis and/or deeply invasive tumors at the time of diagnosis.
 Recurrence is common and usually occurs systemically regardless of the initial surgical procedure.
Local resection with free margins does not increase the risk of local or regional recurrence, and APR
offers no survival advantage over local excision.
 Because of the morbidity associated with APR, wide local excision is recommended for initial
treatment of localized anal melanoma.
 In some patients, wide local excision may not be technically feasible, and APR may be required if the
tumor involves a significant portion of the anal sphincter or is circumferential.
 The addition of adjuvant chemotherapy, biochemotherapy, vaccines, or radiotherapy may be of benefit
in some patients, but efficacy remains unproven.
MELANOMA

DEPARTMENT OF SURGERY
JONELTA FOUNDATION SCHOOL OF MEDICINE
MODULE- PEPTIC ULCER DISEASE

· The large intestine extends from the ileocecal valve to the anus.
· It is divided anatomically and functionally into the colon, rectum,
and anal canal.
· The wall of the colon and rectum comprise four distinct layers:
mucosa, submucosa, muscularis propria (inner circular muscle,
outer longitudinal muscle), and serosa.
· In the colon, the outer longitudinal muscle is separated into
three tenia coli, which converge proximally at the appendix and
distally at the rectum, where the outer longitudinal muscle layer
is circumferential.
· In the distal rectum, the inner smooth muscle layer coalesces to
form the internal anal sphincter.
· The intraperitoneal colon and proximal one-third of the rectum
are covered by serosa; the mid and lower rectum lack serosa.
ANATOMY

· The colon begins at the junction of the terminal ileum and cecum and extends approximately 150 cm (3 to 5 feet) to
the rectum.
· Rectosigmoid junction:
o This is found at approximately the level of the sacral promontory and is arbitrarily described as the point at
which the three-tenia coli coalesces to form the outer longitudinal smooth muscle layer of the rectum.
· Cecum:
o The cecum is the widest diameter portion of the colon (normally 7.5–8.5 cm) and has the thinnest muscular wall.
o As a result, the cecum is most vulnerable to perforation and least vulnerable to obstruction.
· The ascending colon is usually fixed to the retroperitoneum.
· Transverse colon:
o The hepatic flexure marks the transition to the transverse colon.
o The transverse colon is relatively mobile, but it is tethered by the gastrocolic ligament and colonic mesentery.
COLON LANDMARKS

o The greater omentum is attached to the anterior/superior edge of the transverse colon.
o These attachments explain the characteristic triangular appearance of the transverse colon observed during
colonoscopy.
o The splenic flexure marks the transition from the transverse colon to the descending colon.
o The attachments between the splenic flexure and the spleen (the lienocolic ligament) can be short and dense,
making mobilization of this flexure during colectomy challenging.
· The descending colon is relatively fixed to the retroperitoneum.
COLON LANDMARKS

o The sigmoid colon is the narrowest part of the large intestine
and is extremely mobile.
o Although the sigmoid colon is usually located in the left lower
quadrant, redundancy and mobility can result in a portion of
the sigmoid colon residing in the right lower quadrant.
o This mobility explains why volvulus is most common in the
sigmoid colon and why diseases affecting the sigmoid colon,
such as diverticulitis, may occasionally present as right-sided
abdominal pain.
o The narrow caliber of the sigmoid colon makes this segment of
the large intestine the most vulnerable to obstruction.
SIGMOID COLON

· The arterial supply to the colon is highly variable.
· The superior mesenteric artery branches into
o the ileocolic artery (absent in up to 20% of people) which supplies blood
flow to the terminal ileum and proximal ascending colon;
o the right colic artery, which supplies the ascending colon;
o the middle colic artery, which supplies the transverse colon.
· The inferior mesenteric artery branches into
o the left colic artery, which supplies the descending colon;
o several sigmoidal branches, which supply the sigmoid colon; and
o the superior rectal artery, which supplies the proximal rectum.
· The terminal branches of each artery form anastomoses with the terminal
branches of the adjacent artery and communicate via the marginal artery of
Drummond.
· This arcade is complete in only 15% to 20% of people.
BLOOD SUPPLY

· Except for the inferior mesenteric vein, the veins of the colon
parallel their corresponding arteries and bear the same
terminology.
· The inferior mesenteric vein ascends in the retroperitoneal plane
over the psoas muscle and continues posterior to the pancreas to
join the splenic vein.
· During a colectomy, this vein is often mobilized independently and
ligated at the inferior edge of the pancreas.
BLOOD SUPPLY

· The lymphatic drainage of the colon originates in a network of
lymphatics in the muscularis mucosa.
· Lymphatic vessels and lymph nodes follow the regional arteries.
· Lymph nodes are found
o on the bowel wall (epicolic),
o along the inner margin of the bowel adjacent to the arterial
arcades (paracolic),
o around the named mesenteric vessels (intermediate), and
o at the origin of the superior and inferior mesenteric arteries
(main).
LYMPHATIC DRAINAGE

· The colon is innervated by both sympathetic (inhibitory) and
parasympathetic (stimulatory) nerves, which parallel the course
of the arteries.
· Sympathetic nerves arise from T6–T12 and L1–L3.
· The parasympathetic innervation to the
oright and transverse colon vagus nerve
oleft colon arise sacral nerves S2–S4 to form the nervi
erigentes.
NERVE SUPPLY

· The rectum is approximately 12 to 15 cm in length.
· Three distinct submucosal folds, the valves of Houston, extend into the rectal lumen.
· Posteriorly
oThe presacral fascia separates the rectum from the presacral venous plexus and the pelvic
nerves.
o At S4, the rectosacral fascia (Waldeyer’s fascia) extends anteriorly and caudally and
attaches to the fascia propria at the anorectal junction.
· Anteriorly
o Denonvilliers’ fascia separates the rectum from the prostate and seminal vesicles in men
and from the vagina in women. The lateral ligaments support the lower rectum.
· The anatomic anal canal extends from the dentate or pectinate line to the anal verge.
ANORECTAL LANDMARKS

· The dentate or pectinate line
o marks the transition point between columnar rectal
mucosa and squamous anoderm.
o surrounded by longitudinal mucosal folds, known as the
columns of Morgagni, into which the anal crypts empty.
these crypts are the source of cryptoglandular
abscesses
· The anal transition zone includes
omucosa proximal to the dentate line that shares
histologic characteristics of columnar, cuboidal, and
squamous epithelium.
o the proximal extent of this zone is highly variable and
can be as far as 15 cm proximal to the dentate line.
ANORECTAL LANDMARKS

· The superior rectal artery arises from the terminal branch of the inferior mesenteric
artery and supplies the upper rectum.
· The middle rectal artery arises from the internal iliac; the presence and size of these
arteries are highly variable.
· The inferior rectal artery arises from the internal pudendal artery, which is a branch of
the internal iliac artery.
· A rich network of collaterals connects the terminal arterioles of each of these arteries,
thus making the rectum relatively resistant to ischemia.
· The venous drainage of the rectum parallels the arterial supply.
· The superior rectal vein drains into the portal system via the inferior mesenteric vein.
· The middle rectal vein drains into the internal iliac vein.
· The inferior rectal vein drains into the internal pudendal vein, and subsequently into the
internal iliac vein.
· A submucosal plexus deep to the columns of Morgagni forms the hemorrhoidal plexus
and drains into all three veins.
ANORECTAL VASCULAR SUPPLY

· Lymphatic drainage of the rectum parallels the vascular supply.
· Lymphatic channels in the upper and middle rectum drain superiorly into the inferior mesenteric lymph nodes.
· Lymphatic channels in the lower rectum drain both superiorly into the inferior mesenteric lymph nodes and laterally into the
internal iliac lymph nodes.
· The anal canal has a more complex pattern of lymphatic drainage.
o Proximal to the dentate line, lymph drains into both the inferior mesenteric lymph nodes and the internal iliac lymph nodes.
o Distal to the dentate line, lymph primarily drains into the inguinal lymph nodes, but can also drain into the inferior mesenteric
lymph nodes and internal iliac lymph nodes.
ANORECTAL LYMPHATIC DRAINAGE

· Both sympathetic and parasympathetic nerves innervate the anorectum.
· Sympathetic nerve fibers
o derived from L1–L3 and join the preaortic plexus.
· The preaortic nerve fibers then extend below the aorta to form the hypogastric plexus, which subsequently joins the
parasympathetic fibers to form the pelvic plexus.
· Parasympathetic nerve fibers
o known as the nervi erigentes and originate from S2–S4.
o These fibers join the sympathetic fibers to form the pelvic plexus.
· The internal anal sphincter is innervated by sympathetic and parasympathetic nerve fibers; both types of fibers inhibit sphincter
contraction.
· The external anal sphincter and puborectalis muscles are innervated by the inferior rectal branch of the internal pudendal nerve.
· The levator ani receives innervation from both the internal pudendal nerve and direct branches of S3 to S5.
· Sensory innervation to the anal canal is provided by the inferior rectal branch of the pudendal nerve.
· While the rectum is relatively insensate, the anal canal below the dentate line receives somatic innervation.
ANORECTAL NERVE SUPPLY

CASE 1
- 33-year-old female comes to see you complaining of perirectal pain
What are your differential diagnoses? How to rule out?

What pertinent questions will you ask during history taking? Why?
Questions related to pain:
· How long has it been present?
· Is it constant?
· What makes it better or worse?
· Is the pain increasing or decreasing?
· What is the quality of the pain?
· Patients with thrombosed or incarcerated (non-reducible prolapsed) hemorrhoids
usually present with severe, constant pain that has come on suddenly.
· Another diagnosis that has a characteristic pain quality is an anal fissure and pain is
described as “passing glass” during defecation or having “a sharp knife poking” the
anus.
· Pain that is constant but comes on gradually over the course of several days is
characteristic of a perianal or perirectal abscess or an anal sexually transmitted
disease (i.e., syphilis or herpes).
· Pain that worsens over many weeks or months is typical of proctitis and malignancies.
· In general, moderate or mild hemorrhoidal disease is not associated with significant
pain, though patients may report some discomfort or itching in the area.

Questions related to bleeding:
· Presence of bleeding?
· How much is the bleeding?
· What is the location of the blood: on the toilet paper? In the toilet water?
· On top of the stool, or mixed in with the stool?
· Are there symptoms of anemia?
· Bleeding can occur with pilonidal disease
· Thrombosed external hemorrhoids may have mild bleeding seen on the toilet paper or
in the underwear.
· Malignancies often bleed with even gentle touch or manipulation.
· Internal hemorrhoids classically bleed with bowel movements, resulting in blood on the
tissue or in the toilet water and coating the stools.
· Anal fissures also have a similar bleeding pattern, though these are often associated
with pain.
· Proctitis patients may have bright or darker red bleeding.

Question related to presence of mass:
· Presence of mass?
· Is there a mass or swelling noted by the patient?
· Is it new?
· Is it enlarging?
· Is it always present or does it at times disappear?
· Is there more than one mass?
· Anal fissures can be associated with an anal skin tag (also known as a sentinel pile)
that patients may notice.
· Patients with intermittent grade II or grade III hemorrhoids can have protrusion of
tissue.
· Patients with anal condyloma can also note new masses, which tend to be small and
multiple.
· Other more concerning things can also present as a new mass, including anal cancers
· Less commonly, rectal prolapse can also present as a new large mass that can be
confused with hemorrhoids

Question related to drainage:
· Presence of drainage?
· How much?
· What is the character?
· The classic draining lesion in the perianal region is a perianal fistula, which produces
scant, thick yellow or greenish-tinged discharge.
· Abscesses that have spontaneously opened can produce some drainage, which is
usually copious at first and rapidly decreases in volume.
· Prolapsed internal hemorrhoids or rectal prolapse can also produce some drainage,
though this tends to be thin, white or clear drainage and occasionally pink-tinged.

How do you do your digital rectal exam?
· Digital rectal exam (DRE) is to check the lower rectum, pelvis, and lower belly for
cancer and other health problems, including:
o Prostate cancer in men
o Blood in the stool or an abnormal mass in the anus or rectum
o Uterine or ovarian cancer in women, along with a vaginal examination
· The patient lies on their back on an exam table and feet in raised stirrups. Patient
should be relaxed and take a deep breath before gently inserting a lubricated, gloved
finger into the rectum.
· The goal is to feel the reproductive organs and the bowel.
· We also check for abnormalities in the internal organs by applying pressure on the
lower abdomen or pelvic area with the other hand.

Will you request for further diagnostics? What? And Why?
· Any patient with anal/perianal symptoms requires
· A careful history and physical, including a digital rectal examination.
Other studies such as
o Defecography
o Manometry
o CT scan
o MRI
o Contrast enema
o Endoscopy
o Endoanal ultrasound
o Exam under anesthesia may be required to arrive at an accurate diagnosis.

ANOSCOPY
· If a patient has significant pain on exam, and a cause for the pain
cannot be determined in the office, then an exam with sedation can be
done in the GI lab or in the operating room, if needed.
· The anoscope allows one to see the whole anal canal and, depending on
patient habitus and type of anoscope used, it can also allow one to see
the distal rectum for 2- 4cm above the dentate line.
· It is helpful to evaluate internal hemorrhoids, the extent of a small anal
cancer or anal condyloma within the anal canal, as well as to look for
internal fistula openings.
· The patient can be placed in a kneeling position on a table, or in the
lateral decubitus position.
· The examiner also uses a lamp to shine within the scope, though most
commonly used anoscopes now have a small light built into the handle

PROCTOSCOPY
· This does not require a bowel prep, but for best evaluation, a patient will perform one
or two enemas prior to the procedure to allow the rectum to be free from stool.
· This also does not require sedation if the patient does not have severe pain or anxiety,
and can be routinely done in the office.
· Patients may be positioned in the knee-chest position but more frequently, they are
either positioned in a lateral decubitus position or on a procto table.
· This is frequently performed to evaluate malignancies that may be extending more
proximal than what can be seen by an anoscope.
· This is the standard technique used to measure the distal edge of a higher tumor from
the anal verge, as is done for rectal cancers, to determine the location in the rectum.
· The rigid scope allows a straight measurement to be taken, unlike a flexible scope that
can lead to inaccuracies due to looping or flexing of the scope. Since the entire rectum
can be visualized, this is an ideal scope to evaluate for proctitis and to perform
biopsies of any lesions in the rectum

FLEXIBLE
SIGMOIDOSCOPY
· This is 60 cm long flexible endoscopic scope quite easy to reach the splenic flexure and
even the transverse colon using this technique.
· This can also be performed with sedation and a small prep of enemas and oral
laxatives. If performed in a Gastroenterology or Endoscopy lab, sedation is often used
which makes examining the descending and transverse colon more comfortable for
the patient. In combination with a stool test of occult blood,
· a flexible sigmoidoscopy can be used for colorectal cancer screening since more
cancers affect the left colon than the right.
· It is also frequently used for younger patients without significant family history to
asses them for rectal bleeding that does not have other concerning signs, such as
anemia.
· Patients can be positioned on the procto-table or lateral decubitus position in the
office; in the GI lab, the patients are placed in the lateral decubiti position.
· Biopsies can be performed through the scope along with tattoo and injections for
locating the lesion, and bleeding control, when needed.
· While polypectomy snares can technically be introduced through the scopes, unless
the patient is fully bowel prepped, snare polypectomy with electrocautery is avoided
due to combustible gas that may be present in an unprepped patient.

COLONOSCOPY
· The colonoscope is like the flexible scope but longer, about 165-180cm, depending on
brand and model.
· This scope can reach to the cecum and even intubate into the terminal ileum.
· This is the scope that is used for screening for colon cancer, and for surveillance.
· The patients are fully bowel prepped and, therefore, biopsies of larger masses and
snare polypectomy can be performed.
· This is performed in the GI lab with IV sedation as scoping the transverse and
ascending colon can be uncomfortable.
· Patients are positioned in the lateral decubitus position

How will you manage this patient? (based on differential diagnoses)
· Management Based on Differential Diagnosis
Hemorrhoids
o Bleeding from first- and second-degree hemorrhoids often improves with the addition of dietary fiber, stool softeners,
increased fluid intake, and avoidance of straining.
o Associated pruritus often may improve with improved hygiene.
Anal Fissure:
o First-line therapy -bulk agents, stool softeners, and warm sitz baths. The 2% lidocaine jelly or other analgesic creams
can provide symptomatic relief.
o Nitroglycerin ointment -improve blood flow
o Both oral and topical calcium channel blockers (diltiazem and nifedipine) have also been used to heal fissures
o Botulinum toxin (Botox) causes temporary muscle paralysis. It is an alternative to surgical sphincterotomy for chronic
fissure.
o Surgical therapy -lateral internal sphincterotomy
The aim of this procedure is to decrease spasm of the internal sphincter -open or closed technique.

How will you manage this patient? (based on differential diagnoses)
Rectovaginal Fistula
o The treatment of rectovaginal fistula depends on the size, location, etiology, and condition of surrounding tissues.
o Because up to 50% of fistulas caused by obstetric injury heal spontaneously
o Low and mid-rectovaginal fistulas are usually best treated with an endorectal advancement flap
o Fistulas caused by malignancy should be treated with resection of the tumor
Perianal Abscess
o Most perianal abscesses can be Treated by draining under local anesthesia in the office, clinic, or emergency
department.
o Larger, more complicated abscesses may require drainage in the operating room
o A skin incision is created, and a disk of skin excised to prevent premature closure

 A 63-year-old woman presents to the office for evaluation of a painful
anal mass.
CASE 2

WHAT PERTINENT QUESTIONS WILL YOU ASK DURING HISTORY TAKING? WHY?
· Name, Age, Occupation, Marital status
Questions related to the chief complaint
o When did you first notice the mass?
o Have you noticed any bleeding?
o Do you feel any itchiness?
o Have you ever suffered from this condition in past?
o Do you suffer from constipation or diarrhea?
o If the patient underwent any trauma due to hard stool or strain due to diarrhea
o Have you been diagnosed with inflammatory bowel disease in past?
o Have you been diagnosed with any malignant disease in past?
Family history:
o Does anyone in your family suffer from this type of condition?
o Does anyone in your family have cancer, anal cancer?

WHAT PERTINENT QUESTIONS WILL YOU ASK DURING HISTORY TAKING? WHY?
Personal and Sexual history:
o Are you sexually active or have been practicing unprotected sex in past? If yes have you had anal sex?
o Have you been diagnosed or underwent treatment for any sexually transmitted diseases in the past?
o Do you take any medications at the moment?
o Do you have any other complaints?
o Have you been diagnosed with diabetes or hypertension?
o Have you noticed any abdominal symptoms like pain, nausea or vomiting?
o Do you smoke or drink alcoholic beverages? Do you use any illicit drugs?
What further Diagnostics will you request?
1. Digital rectal examination
2. CT-Scan of Abdomen

HOW WILL YOU MANAGE THIS PATIENT?
· Fiber supplements moderately improve overall symptoms and bleeding and should be recommended at an early stage.
· Other lifestyle modifications such as improving anal hygiene, taking sitz baths, increasing fluid intake, relieving
constipation, and avoiding straining are used in primary care and may help in the treatment and prevention of
hemorrhoids, although the evidence for this is lacking.
· Over the counter topical preparations that contain a combination of local anesthetics, corticosteroids, astringents, and
antiseptics are available, and these can alleviate symptoms of pruritus and discomfort in hemorrhoidal disease.
o Long term use of these agents should be discouraged, particularly steroid creams, which can permanently damage or
cause ulceration of the perianal skin.
· Venotonics such as flavonoids have been used as dietary supplements in the treatment of hemorrhoids.

OUTPATIENT TREATMENTS
· RUBBER BAND LIGATION
· INJECTION SCLEROTHERAPY
· OTHER TECHNIQUES - INFRARED COAGULATION can be used to treat 1st or 2nd degree hemorrhoids. Although it is
associated with few complications it seems to be less effective than banding and is not widely used
SURGERY
· OPEN AND CLOSED HAEMORRHOIDECTOMY
· DOPPLER GUIDED HAEMORRHOIDAL ARTERY LIGATION
· STAPLED HAEMORRHOIDOPEXY

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