Hello! This is a quick review PPT for medical students. It includes description at a glance of all the commonly occuring benign anal and perianal conditions like; haemorrhoids, fissure in ano, fistula in ano etc. Hope this is worth sharing

1. BENIGN ANAL AND PERIANAL CONDITIONS
Dr. Ankita Singh
Surgery Department

2. OUTCOMES
• Describe surgical anatomy of anal canal
• List the types of anal and peri anal diseases and
there common occurrence
• Describe pathology, clinical features, investigations
and treatment of common diseases

3. SURGICAL ANATOMY
• Length of anal canal- 3 to 5cm
• Extends from anorectal junction above to anal verge
below
• Anatomical anal canal – dentate line to perianal skin
• Surgical anal canal- anorectal junction(ring) to anal
verge
• Anal transition zone(ATZ)- 1-2 cm of anal mucosa
proximal to dentate line shares histological
characterstics of squamous as well as columnar
• Columns of Morgagni- longitudinal mucosal folds
around dentate line, into which anal crypts empty

4. ANORECTAL RING
• Marks the junction between rectum & anal canal
• Digitally palpable on DRE
• Formed by joining of-
1. puborectalis muscle,
2. deep external sphincter,
3. conjoined muscle, and
4. highest part of internal sphincter.

5. PUBORECTALIS MUSCLE
• Funnel shaped muscle
• Maintains angle between anal canal & rectum
• Important for continence mechanism
• Innervated by Sacral somatic nerves

6. ANAL SPHINCTERS
• Comprised of 3 layers-
1. Internal sphincters
2. Intersphincteric space
3. External sphincters

7. INTERNAL SPHINCTER
• Involuntary muscle
• Thickened distal continuation of circular coat of
rectum
• In a tonic state of contraction
• Receives intrinsic nonadrenergic and noncholinergic
fibres, stimulation of which causes release of NO
which induces IS relaxation

8. EXTERNAL ANAL SPHINCTER
• Single, somatic, voluntary muscle
• Divided by lateral extensions from longitudinal
muscle into 3 portions
1. Deep
2. Superficial
3. Subcutaneous
• Innervated by Pudendal Nerve

9. DENTATE LINE
• Also known as Pectinate line, is an important
surgical landmark
• Represents the site of fusion of proctodaeum
and post-allantoic gut.
• Site of crypts of Morgagni through which anal
ducts that communicate with anal glands
open into anal lumen.

10. Above
• Pink Mucosa
• Columnar epithelium
• Superior Rectal Artery
• Portal circulation
• Autonomic Nervous
system
• Painless
Below
• Parchment coloured
mucosa
• Stratified Squamous
epithelium
• Inferior Rectal Artery
• Systemic circulation
• Somatic innervation
• Painful

12. HAEMORRHOIDS

14. HAEMORRHOIDS
• Means “blood flow” (Greek: haima-blood, rhoia-
flow)
• Piles (Latin: pila-a ball)
• Definition: symptomatic enlargement and distal
displacemnet of the normal anal cushions

15. ANAL CUSHIONS
• Uneven folds of mucosa & submucosa just above the
dentate line
1. Left lateral
2. Right posterior
3. Right anterior
• Contains sub epithelial meshwork of supporting
tissues
• Site of dense arterio venous plexus

16. CAUSES OF HAEMORRHOIDS
• Constipation
• Fiber deficient diet
• Straining to pass stool
Shearing forces acting on the anus lead to caudal
displacement of anal cushions.
Fragmentation of supporting structures leads to
loss of elasticity of cushions such that they no longer
retract following defecation.

17. SYMPTOMS OF HAEMORRHOIDS
• Bright –red , painless bleeding
• Mucus discharge
• Prolapsed mass
• Pain only when prolapsed (below dentate line) or
thrombosed

18. GRADES OF HAEMORRHOIDS

19. COMPLICATIONS
• Profuse bleeding
• Ulceration
• Thrombosis
• Abscess
• Gangrene

20. MANAGEMENT
• 1st DEGREE: Conservative (Medical)
• 2nd DEGREE: BARRON’S BANDING
• 3rd & 4th DEGREE: Open Haemorrhoidectomy
(Milligan Morgan)Or Closed (Hill-Ferguson) Or
Stapled Haemorrhoidopexy

22. ANAL FISSURE

23. FISSURE IN ANO
• A longitudinal split in the anoderm of distal anal canal
• Not beyond Dentate line
• Site- midline/ posteriorly
• Eitiology-spasm of internal sphincters leading to vascular
insufficiency
• Causes-
strained evacuation of hard stools
trauma
STD
underlying malignancy

24. CLINICAL FEATURES OF ANAL FISSURE
• Severe anal pain on defecation
• Bright red bleeding (streak of blood on stools)
• Sentinel tag
• Discharge, itching

25. ECTOPIC SITE SUGGESTS A MORE
SINISTER CAUSE!!!
• Crohn’s Disease
• TB
• HIV
• Syphilis
• Chlamydia
• Chancroid
• Lymphogranuloma Venereum
• HSV
• Cytomegalovirus
• Kaposi’s Sarcoma
• B cell Lymphoma
• Squamous cell carcinoma

26. MANAGEMENT OF ANAL FISSURE
1. Conservative management(initially, chronic fissure):
• Stool bulking agents
• Stool Softeners
• Local Anaesthetic cream
• 0.2 % Glyceryl Trinitrate or 2% Diltiazem cream
• Sitz bath and dietary modifications
2. Surgery , if above fails- lateral anal sphincterotomy or
anal advancement flaps

27. FISTULA IN ANO

28. FISTULA IN ANO
• Definition: It is a chronic abnormal communication
lined by granulation tissue, which connects anorectal
lumen to an external opening on the skin of
perineum or buttock.
• Aetiology:
1.cryptoglandular (90%)
2.non cryptoglandular causes
trauma, Crohn’s ds, malignancy, radiation, TB,
actinomycosis, chlamydia etc.

29. PRESENTATION OF ANAL FISTULA
• Intermittent perianal purulent discharge
• Pain (on and off)
• Previous episode of anorectal sepsis
• H/O previous surgical interventions

30. TYPES
1. Park’s classification:
intersphincteric (45%)
trans sphincteric (40%)
Suprasphincteric
extra sphincteric
2. High vs Low
3. Simple vs Complex

31. Goodsall’s Rule

32. MANAGEMENT
• SURGERY IS MAINSTAY (recurrence common):
• Principles:
1. Fistula anatomy- MRI/EUS
2. Identify relations- sphincters
3. Drain- all sites of infection , if any
4. Eradicate- track and extensions
5. Preserve anal function
• Procedures:
1. Fistulotomy+curetting of tract
2. Fistulectomy
3. Flap procedures(advancement)

33. 4. LIFT (ligation of intersphincteric fistula tract)
5. VAAFT
6. Fistula plug
7. Seton technique

38. Synthetic, bioabsorbable scaffold of
polyglycolic
acid and trimethylene carbonate copolymer

40. ANAL ABSCESS

41. PRURITIS ANI

42. HIDRAENITIS SUPPURATIVA

43. ANAL WARTS

44. MALIGNANCY

45. THANK YOU