The document discusses various diseases and conditions of the colon including: 1. Infectious diseases like amebic colitis caused by Entamoeba histolytica and pseudomembranous colitis caused by Clostridium difficile overgrowth. 2. Inflammatory conditions like diverticulitis which is the inflammation or infection of diverticula in the colon. It can lead to complications like abscesses, fistulas or hemorrhage. 3. Neoplastic polyps which are growths in the colon that can become cancerous if left untreated. Large or villous polyps have a higher risk of harboring cancer.

1. COLON James Taclin C. Banez, MD, FPCS, FPSGS, DPBS, DPSA

2. Anatomy / Physiology: Location, blood supply & venous drainage, lymphatic drainage and nerve supply Function: absorption of fluid and electrolyte Transport and temporary storage of feces

3. Anatomy / Physiology:

4. Amebic colitis: Entamoeba histolytica Primary – colon : secondary – liver Fecal to oral route: (sexual contact, contaminated water & food) Abdominal pain, bloody diarrhea, tenesmus, fever Complication: megacolon / colonic obstruction (partial) --- > AMEBOMA – mass of inflammatory tissue Dx: clin hx / stool exam / indirect hemagglutination test Tx: metronidazole / iodoquinol : rare COLECTOMY Infectious:

5. Infectious: Pseudomembranous colitis: Complication of antibiotics ---> alteration of normal flora Overgrowth of Clostridium deficile : Has cytopathic and enteropathic toxins Develops 6wks after: Clindamycin Ampicillin Cephalosporin Dx: - history - latex fixation test - colonoscopy ( Pseudomembrane ) Tx: - stopped antibiotic ----> metronidazole/vancomycin - cholestyramine ---> binds w/ toxin - Toxic megacolon---> total colectomy w/ ileostomy

6. Infectious: Salmonellosis: Salmonella typhi (typhoid fever) Dx: perforation / bleeding Tx: antibiotic / transfusion / right hemicolectomy w/ or w/o ileostomy

7. Volvulus: Twisting of an air-filled segment of bowel about its narrow mesentery ---> OBSTRUCTION -------> STRANGULATION ----> GANGRENE ----> PERFORATION ----> PERITONITIS SIGMOID VOLVULUS (90%): Redundant sigmoid colon w/ a narrow based mesocolon Sx: colicky abd. pain, distention obstipation, rectal collapse s/sx of dehydration

8. Volvulus: SIGMOID VOLVULUS (90%): Dx: FPA – inverted U shaped sausage like loop (diagnostic) Barium enema – bird beaks deformity Gangrene – chills/fever, leukocytosis w/ s/x of peritoni

9. Volvulus: SIGMOID VOLVULUS (90%): Tx: (-) Signs of Peritonitis: Reduced the volvulus --->prepare for elective colonic surgery for the recurrence is 40%: - use of flexible scope (+) Signs of Peritonitis / Unsuccessful reduction: Sigmoidectomy w/ Hartmanns or Divine’s colostomy

10. Volvulus: Cecal Volvulus: Tx: reduction is impossible --> emergency exploration (+) Gangrene: - right hemicolectomy - end to end ileo-transverse colostomy (-) Gangrene: a) – same – b) Cecopexy c) Pure detorsion (recurrence 7 – 15%) Transverse colon volvulus: Rare, due to it’s broad based and short mesentery Tx: resection of redundant transverse colon

11. DIVERTICULOSIS: Abnormal pouch from the wall of a hollow organ Types: True diverticula (rare) – right side False diverticula (common – due to low fiber diet: left side) Rare before 30y/o; common > 75 y/o Female > Male Etiology: Unknown Theories by Painter et al: Contraction ring (thickening of circular muscle) Depletion of dietary fibers ---> narrow lumen Deteriorating integrity of the bowel wall ; elderly has lower tensile strength, lowest in the sigmoid)

12. DIVERTICULOSIS: Pathology: Site: anteriole penetrates the mesenteric side of the antimesenteric teniae coli: Sigmoid (50%) Descending colon (40%) Entire colon (2-10%)

13. DIVERTICULOSIS: Clinical Manifestation: Majority are asymptomatic Symptomatic patients: Uncomplicated painful diverticular dse. (+) LLQ pain and tenderness; (+) change in bowel habits (-) rebound tenderness (-) fever nor leukocytosis Dx: Gastrografin enema Tx: high fiber diet

14. DIVERTICULOSIS: Clinical Manifestation: Symptomatic patients: Complicated diverticular disease: Diverticulitis / Peridiverticulitis: Infected diverticula Diverticula is filled up ---> obstructed ---> mucus secretion and bacteria ---> inflammation at the apex ---> unresolved --> extend intramurally ---> perforate.

15. DIVERTICULOSIS: Diverticulitis / Peridiverticulitis: Sx: - left lower abd. pain / chills & fever / bowel habit changes - (+) abd. Tenderness, distension if w/ partial obstruction - pararectal tenderness - frequency / urgency of urination (inflamed bladder)

16. DIVERTICULOSIS: Diverticulitis / Peridiverticulitis: Dx: Cln. Hx. Ct scan of the abd / utrasonography (thickened wall & abscess can be seen) Contrast enema / sigmoidoscopy (risk of spreading infection)

17. DIVERTICULOSIS: Diverticulitis / Peridiverticulitis: Tx: NPO or liquid diet Broad spectrum antibiotic Meperidine (not morphine) If improved  endoscopy to r/o CA

18. DIVERTICULOSIS: Complicated diverticular disease: Perforated Diverticulitis: Sx: - similar to appendicitis (Phlegmon mass) - (+) pneumoperitoneum - Classification of perforated diverticulitis (Hinchy) Stage I : abscess confined by mesentery of colon Stage II : pelvic abscess Stage III : generalized peritonitis Stage IV : fecal peritonitis

19. DIVERTICULOSIS: Perforated Diverticulitis: Tx: initial nonoperative: - NPO / IVF / Broad spectrum antibiotic/ meperidine Stage I & II: (+) improvement  elective Surgery (4 wks) (-) improvement  percutaneous drainage (-) improvement ---> Surgery

20. DIVERTICULOSIS: Perforated Diverticulitis: Tx: initial nonoperative: - NPO / IVF / Broad spectrum antibiotic/meperidine Stage III & IV: explore after initial resuscitation a. sigmoidectomy w/ primary anastomosis b. sigmoidectomy w/ Hartmann’s colostomy c. resection w/ primary anastomosis w/ proximal diverting stoma d. drainage w/ diverting transverse colostomy

21. DIVERTICULOSIS: Complicated diverticular disease: Obstructing diverticulitis: 90% partial – due to spasm, edema & ileus 10% complete – fibrosis and stenosis S/Sx: of large intestinal obstruction Tx: conservative mx (3-5 days) ---> (-) response -----> cecum dilates to 10-12 cm. ---> surgery.

22. DIVERTICULOSIS: Clinical Manifestation: Symptomatic patients: Complicated diverticular disease: Acute hemorrhage: Due to erosion of the peridiverticular arteriole by inspissated stool w/in the diverticulum and thinning of the tunica media

23. DIVERTICULOSIS: Acute hemorrhage: Resuscitate the patient Locate the site of bleeding (Tc labeled RBC/selective arteriography) Vasopressin infusion, transcatheter emboli infusion using gelfoam Colonoscopy Tx: segmental resection / blind subtotal colectomy

24. DIVERTICULOSIS: Complicated diverticular disease: Fistula formation: Bladder, vagina, small bowel, skin Dx: - clin hx & PE (pneumaturia, fecaluria and frequent UTI) - cystoscopy, IE, speculum exam - methylene blue enema - colonoscopy to r/o CA

25. DIVERTICULOSIS: Fistula formation: Tx: - bowel rest w/ TPN or elemental diet - Foley catheter (10 days postop) / antibiotic - placement of ureteral catheter prior to celiotomy - sigmoidectomy w/ primary anastomosis - fistulectomy and closure of secondary opening

26. Hemorrhage from the Colon: Diverticular disease Angiodysplasia (Vascular ectasia, AV malformation, Angiectasia )

27. ANGIODYSPLASIA Acquired lesion Proximal colon (cecum) where tension is greatest (Laplace’s law – tension in the wall is highest in the widest circumference) Rare < 40y/o; common in elderly Etiology: - chronic intermittent obstruction of submucosal veins due to repeated muscular contraction

28. ANGIODYSPLASIA Dx: - Nuclear scan / angiography = (vascular tuft and early filling of veins) - colonoscopy = distinct red mucosal patch

29. Bleeding distal to the ligament of Treitz: Diverticular disease Angiodysplasia Inflammatory bowel disease Ischemic colitis Tumor Anticoagulant therapy Gastroduodenal hge -> can present as rectal bleeding It is more important to identify the location of the BLEEDING POINT than the immediate diagnosis as the cause.

30. Diagnostic: Nuclear imaging (bleeding scan/scintigraphy) Technetium-Sulfur Colloid Scan Sensitive (0.5ml/min) Autologous labeled RBC scan Stays in the circulation for as long as 24 hrs (monitoring) (1ml/min bleeding) Mesenteric Angiography Done once patient’s condition is stable and hydration is adequate Identify bleeding point ---> 1ml/min Could be therapeutic ---> Vasopressin/emboli Vascular taft (A) Early filling vein (B)

31. Diagnostic: Emergent colonoscopy: Possible w/ use of GOLYTELY Therapeutic Treatment: Restore intravascular volume (85% stop spontaneously) Persistent --> celiotomy (segmental or total colectomy)

32. Ischemic Colitis Due to occlusion of major mesenteric vessel Thrombosis, embolization, iatrogenic ligation Elderly: - contraceptive pills - medical problems: a) cardiovascular disease b) DM c) Rheumatoid arthritis Splenic flexure – most common site in the colon

33. Ischemic Colitis: Clinical Syndrome Based on: Extent of vascular occlusion Duration of occlusion Efficiency of collateral circulation Extent of secondary bacterial invasion Reversible or Transient Ischemic Colitis: Partial mucosal slough that healed after 2-3 days Stricturing Ischemic Colitis: Arterial occlusion ---> hge’ic infarct of mucosa ---> ulcerates ----> bacterial invasion of bowel ---> fibrosis

34. Ischemic Colitis: Clinical Syndrome Based on: Gangrenous ischemic Colitis: Complete arterial occlusion ---> full thickness infarction ---> gangrene ---> perforation ----> PERITONITIS.

35. Ischemic Colitis: Symptoms: Depends on the stage of the lesion Acute mild to moderate generalized or lower abdominal crampy pain ---> HEMATOCHEZIA Hyperactive bowel sound ---> silent Abdominal tenderness ---> persist --->r/o peritonitis

36. Ischemic Colitis: Diagnosis: Clinical hx & PE FPA ---> adynamic ileus (stops at the involved segment); Pneumoperitoneum Contrast enema (water soluble) - thumb printing in the mucosa Endoscopy (risky)

37. Ischemic Colitis: Treatment: Emergency celiotomy - segmental resection w/ primary anastomosis or colostomy

38. Fecal impaction: Is the arrest and accumulation of the feces in the rectum or colon (dehydrated feces). Overflow diarrhea w/o relief of the sense of rectal fullness Result to stercoral ulcer --> bleeding and perforation Mx: - tap water enema / manual extraction - hot sitz bath

39. Inflammatory Bowel Diseases: Ulcerative colitis (Mucosal Ulcerative Colitis / Idiopathic Ulcerative Colitis): involve the colonic mucosa male > female limited to the colon and rectum Crohn’s Disease (Chronic Interstitial Enteritis/Regional Ilietis): transmural inflammation anywhere in the GIT extraintestinal symptoms proceeds those of intestinal symptoms female > male

40. Inflammatory Bowel Disease: Signs and Symptoms Crohn’s Disease Ulcerative Colitis Symptoms diarrhea +++ +++ rectal bleeding + +++ tenesmus 0 +++ abdominal pain +++ + fever ++ + vomiting +++ 0 weight loss +++ + Signs perianal disease +++ 0 abdominal mass +++ 0 malnutriton +++ +

41. Inflammatory Bowel Diseases: Ulcerative Colitis Crohn’s Colitis Usual Location rectum, left colon anywhere Rectal Bleeding common, continuous uncommon, intermittent Rectal involvement almost always approximate 50% Fistulas rare common Ulcers shaggy, irregular, continuous distribution linear w/ transverse fissures (cobblestone) Bowel stricture rare (suspect carcinoma) common Carcinoma increase incidence increased incidence Toxic dilatation of colon Occurs in both

42. Medical Therapy for Ulcerative Colitis & Crohn’s Disease Sulfasalazine Metronidazole Crohn’s ileocolitis & colitis Perineal colitis Not effective in active ulcerative colitis Corticosteroid Oral for mild to moderate active ulcerative colitis and Crohn’s disease Parenteral for severe or toxic ulcerative colitis or Crohn’s disease Immunosuppressive agents: Steroid sparing Refractory disease

43. Indications for Surgical Interventions for Ulcerative Colitis: Active disease unresponsive to medical therapy Risks of cancer Severe bleeding

44. Surgical treatment for Ulcerative Colitis Proctocolectomy w/ Brooke ileostomy: curative w/ one operation Colectomy w/ ileorectal anastomosis: not curative; cancer risk persists (5-50%) contraindicated for severe rectal dse, rectal dysplasia and rectal CA Total proctocolectomy w/ ileoanal anastomosis w/ pouch: curative w/ continence contraindicated for Crohn’s dse, diarrhea, rectal CA

45. Surgical treatment for Ulcerative Colitis

46. Indications for Surgical Treatment of Crohn’s Dsease Ileocolic Crohn’s Disease: Internal fistula and abscess 38% Intestinal obstruction 37% Perianal fistula 15% Poor response to medical therapy 6% Colonic Crohn’s Disease: Internal fistula and abscesses 25% Perianal disease 23% Severe dse w/ poor response to medical therapy 21% Toxic megacolon 19% Intestinal obstruction 12%

47. COLO – RECTAL POLYPS Projection from the surface of the intestinal mucosa regardless of it’s histologic nature: Types: Neoplastic Hamartomatous Inflammatory Unclassified

48. COLO – RECTAL POLYPS Neoplastic Polyps: Invasive CA are common in polyps smaller than 1 cm in diameter and incidence increases w/ increase in size Types Incidence (%) Malignant Potential (%) Tubular 75 5 Villous 10 40 Tubulovillous 15 22

49. COLO – RECTAL POLYPS Neoplastic Polyps: Diagnosis: bleeding per rectum (most common) Villous polyp (large) ---> watery diarrhea and in rare cases can have fluid and electrolyte imbalance do complete examination of the colon - colonoscopy biopsy / transrectal ultrasonography

50. COLO – RECTAL POLYPS Neoplastic Polyps: Treatment: Polypectomy for benign ---> follow up (+) CA in situ ----> polypectomy (+) invasive CA (invade the muscularis mucosa) 9% metastasize to LN if pedunculated 20% metastasize to LN if it invades the stalk or neck 15% metastasize to LN if sessile CANCER SURGERY

51. Neoplastic Polyps: Treatment: If entire mucosal surface is covered by villous tumor ---> segmental resection, if in rectum can do full thickness proximal protectomy w/ colo-anal anastomosis

52. Hamartomatous Polyp: Juvenile Polyp: not precancerous excision Swiss cheese appearance from dilated cystic spaces Familial Juvenile Polyposis Coli: thousands polyps in the colon and rectum can degenerate to adenoma ----> malignancy subtotal colectomy or proctocolectomy

53. Hamartomatous Polyp: Peutz-jegher Syndrome Melanin spot on buccal mucosa, lips, face and digits Polyps of small bowel (always), stomach, colon and rectum (branching of lamina propria like Christmas tree ). Can degenerate into malignancy Cronkhite – Canada Syndrome: GIT polyposis, alopecia, cutaneous pigmentation, atrophy of fingernails and toe nails Cowden’s Syndrome: Autosomal dominant, hamartomas of all three embryonal cell layers Facial trichilemomas, breast cancer, thyroid dse, GIT polyp

54. Infammatory Polyp: Caused by previous attacks of severe colitis resulting in partial loss of mucosa leaving remnants or islands of normal mucosa Occurs after amebic colitis, ischemic colitis and Schistosomal colitis Not premalignant Hyperplastic Polyp: Usually small < 5mm not premalignant > 2cm. have a slight risk of malignant degeneration Saw tooth appearance of the lining epithelial cells

55. COLO – RECTAL POLYPS Familial Adenomatous Polyposis Coli: Inherited non-sex linked autosomal dominant disease w/ hundreds of adenomatous polyps through the entire colon and rectum Gardner’s Syndrome: Familial polyposis, osteomatosis, epidermoid cyst, fibromas of the skin (desmoid tumor) – the most important extra-colonic expression. Tx: - total proctocolectomy w/ ileostomy - colectomy w/ ileorectal anastomosis - examine other members of the family

56. COLO – RECTAL POLYPS Familial Adenomatous Polyposis Coli: Turcot’s Syndrome: Familial polyposis, brains tumors (gliomas or medulloblastomas) Tx: same w/ colorectal involvement

57. Carcinoma of Colon Most common CA of the GIT Older age grp; peak incidence 80y/o male ( > rectum) ; female ( > colon) Etiology: Unknown Hereditary Diet --> low fiber diet and high animal fat Distribution --> shifting to the right side

58. Carcinoma of Colon Macroscopic form: Ulcerating type most common Polypoid or fungating Colloid CA bulky growth w/ gelatinous appearance 10-15% Signet ring cell CA intracellular mucinous Infiltrating CA submucosal spread

59. Carcinoma of Colon Microscopic form: adenocarcinoma Gronnell : based on invasive tendency, glandular arrangement, nuclear polarity and frequency of mitosis. Grade I - low grade / well differentiated Grade II - average grade / mod. differentiated Grade III - high grade / poorly differentiated

60. Carcinoma of Colon Mechanism of Spread: Direct spread Transperitoneal spread Implantation Lymphatic Hematogenous Liver & Lungs – most common distant spread

61. Carcinoma of Colon Duke’s Stage: Depth of bowel wall involvement Presence or absence of LN metastasis Stage A: Invasion at least through the muscularis mucosa but not through the muscularis propria 98% ---> 5yr survival Stage B: Invasion through full thickness of bowel wall; (-) LN 78% ----> 5yr survival

62. Carcinoma of Colon Duke’s Stage: Stage C: LN metastasis, regardless of depth Stage C1 : - only adjacent LN metastasis Stage C2 : - LN involves are nodes at point of ligature of blood vessels 32% 5 yr survival Stage D: Distant metastasis or w/ adjacent organ involvement 0% 5 yr survival

63. TNM Staging of Colonic CA Primary Tumor (T): TX - Primary tumor cannot be assessed T0 - No evidence of primary tumor T1 - Tumor invades submucosa T2 - Tumor invades muscularis proper T3 - Tumor invades through the muscularis proper into the subserosa or into nonperitonealized pericolic or perirectal tissue T4 - Tumor perforates the visceral peritoneum or directly invades the organs or structures

64. TNM Staging of Colonic CA Regional Lymph Node (N): NX – Regional LN cannot be assessed N0 - No regional LN metastasis N1 - Metastasis in 1 to 3 pericolic or perirectal LN N2 - metastasis in 4 or more pericolic or perirectal LN N3 - Metastasis in any LN along the course of a named vascular trunk Distant Metastasis (M): MX – Presence of distant metastasis cannot be assessed M0 - No distant metastasis M1 - w/ distant metastasis

65. TNM Staging of Colonic CA Stage I: T1 –T2 N0 M0 90% 5y/r Survival Stage II: T3 – T4 N0 M0 60 – 80% 5 y/r survival Stage III: Any T N1 M0 Any T N2, N3 M0 20 – 50% 5y/r survival Stage IV; Any T Any N M1 < 5% 5 yr survival

66. Risk Factors for Colorectal CA Aging is the dominant risk factor w/ rising incidence after 50 y/o. Hereditary risk factor: 80% colorectal are sporadic 20% w/ known family hx. Dietary factors: high animal fat (saturated or polyunsaturated fats), but oleic acid (coconut & fish oil does not). Vegetable fiber, Ca, selenium, Vits. A, C, & E are protective Alcohol increase colonic CA Obesity and sedentary lifestyle contributory Smoking increased the incidence

67. Premalignant Diseases of Colon & Rectum Adenoma Familial adenomatous polyposis syndrome Gardner’s syndrome Hamartoma s (familial juvenile polyposis coli & Peutz-Jegher polyp Inflammatory bowel disease Ulcerative colitis Crohn’s disease Schistosomiasis (Billharziasis) – S. mansoni & S. japonicum Utero-sigmoidostomy

68. Carcinoma of Colon Clinical Manifestation: Change in bowel habit classic symptoms Rectal bleeding Weight loss Abdominal pain, bloating and other signs of obstruction Anemia and anorexia Tenesmus, feeling of incomplete evacuation, and rectal bleeding if lesion is in the rectum

69. Screening Modalities For Colonic Tumors Fecal occult blood testing: Annual FOBT screening for asymptomatic 50 y/o Rigid proctoscopy / flexible sigmoidoscopy Colonoscopy: The most accurate and most complete method for examining the colon Air contrast Barium enema: CT colonography (virtual colonoscopy): Colon is insufflated with air and a spiral CT is performed. Useful for imaging the proximal colon in case of obstruction

70. Therapy for Colonic Carcinoma Principle: Objective is to remove the primary tumor w/ its lymphovascular supply Adjacent organs or tissue invaded shd be resected en block w/ the tumor Tumors cannot be removed, a palliative procedure shd be done. Synchronous CA ---> subtotal or total colectomy Metachronous tumor (second primary colon CA) treated similarly Hemorrhage in an unresectable tumor can be controlled w/ angiographic embolization

71. Therapy for Colonic Carcinoma Stage 0: No risk of LN metastasis Pedunculated / sessile polyp -> endoscopic polypectomy If polyp cannot be removed completely segmental resection shd be done Stage I: (T1,N0,M0): Polypectomy --> for uninvolved stalk (pedunculated) Segmental resection: Sessile polyp Pedunculated polyp ( lymphovascular invasion, poorly differentiated or tumor w/in 1mm. of resection margin ---> high risk of local recurence and metastatic spread)

72. Therapy for Colonic Carcinoma Stage II (T3-4,N0,M0): Surgical resection Adjuvant chemotherapy is suggested for: Young patient Moderate to poorly differentiated Stage III (Tany,N1,M0): Surgical resection + adjuvant chemotherapy (5-Fluorouracil, levamisole or leucovorin, capecitabine, irinotecan, oxaliplatin, angiogenesis inhibitor and immunotherapy)

73. Therapy for Colonic Carcinoma Stage IV: (Tany, Nany, M1) Palliative resection of primary and isolated liver metastasis Adjuvant chemotherapy Irresectable ---> diverting colostomy

74. THANK YOU

75. Anorectal Abscess 5 potential spaces: Perianal space Ischiorectal space Intersphincteric space Deep posterior anal space Supralevator space

76. Anorectal Abscess Etiology: Infection of anal gland Organism (fecal & cutaneous flora) E. coli 4. Clostridium sp. Bacteroides fragilis 5. Staphylococcus Streptococcus Manifestation: Pain in the anal region Treatment: Drainage / antibiotic Hygiene Hot sitz bath

77. Anorectal Abscess Types : Perianal abscess Ischiorectal abscess – diffuse swelling of ischiorectal fossa

78. Anorectal Abscess Intersphincteric abscess: No apparent sign of swelling or induration in the perianal area CLUE: --> deep seated tenderness when circum-anal pressure is applied above the dentate line. Drainage: thru the anal canal lining or thru internal sphincteric muscle Supralevator abscess: Uncommon Mimmic acute intra-abdominal condition Etiology: extension of Intersphincteric abscess Ischiorectal abscess Intra-abdominal abscess

79. Necrotizing Peri-anal & Perineal Infection: Etiology: Neglected or delayed treatment of primary anorectal infection Extension of UTI particularly the periurethral gland Manifestation: Pain, tenderness and swelling with crepitation of perianal and scrotum or labia Black spot on the site (necrosis) Treatment: Broad spectrum antibiotic Debridement Hyperalimentation / diverting colostomy &/or cystostomy

80. Fistula-In-Ano: Inflammatory tract w/ secondary opening (external) and a primary opening (internal) in the anal canal. Etiology: Complication of perianal abscess Goodsalls Rule: to locate internal opening Classification of Fistula-in-ano: Inter-sphincteric Trans-sphincteric Supra-sphincteric Extra-sphincteric

81. Fistula-in-ano Manifestation: Previous history of perianal abscess Rule out ulcerative colitis and Crohn’s dse (colonoscopy / barium enema) Treatment: Identify the primary opening (probing/methylene blue/fistulography) Fistulotomy / fistulectomy (healing by secondary intension

82. Fistula-in-ano If fistula is high in relation to anorectal ring do 2 stage procedure: Insert a seton wire or suture to the tract for several wks to create fibrosis Open the fibrous track on the second stage after 6-8 wks

83. Hemorrhoid Are cushions of submucosal tissue in the anal canal composed of connective tissue containing venules, arterioles and smooth muscle fibers. Purposed – aids in anal continence and cushion the anal canal and support the lining during defecation External skin tag Redundant fibrotic skin at the anal verge due to previous thrombosed external hemorrhoid of past operation

84. Hemorrhoid External hemorrhoid Dilated venules of the inferior hemorrhoidal plexus located distal to the pectinate or dentate line

85. Hemorrhoid Internal hemorrhoid: Manifestation: Painless bright red rectal bleeding associated w/ bowel movement Feeling of incomplete evacuation of feces Pain is experienced if w/ complication of anal fissure, stenosis of thrombosis Grade According to Degree of Prolapse: 1 st degree : anal cushion slide down beyond the dentate line on straining Mx: - painless rectal bleeding Tx: - bulk forming agents (psyllium seed) - rubber band ligation

86. Hemorrhoid Rubber band ligation:

87. Hemorrhoid 2 nd degree: Prolapse through the anus on straining but spontaneously reduced 3 rd degree: Requires manual reduction into the anal canal Tx: rubber band ligation / hemorrhoidectomy 4 th degree: Prolapse cannot be reduced hemorrhoidectomy

88. Anal Fissure Tear from the dentate line up to the anal verge lined by skin Seen in young and middle age group Majority occurs at the at the posterior midline due to poor muscular support

89. Anal Fissure Etiology: Passage of large hard stool Conditions ( Crohn’s dse, ulcerative colitis, syphilis’ tuberculosis and leukemia) Manifestation: Burning pain during and after bowel movement Bright red blood on toilet paper Diagnosis: Rectal examination / proctosigmoidoscopy Treatment: Conservative: - anal hygiene / bulk forming agents - hot sitz bath - local anesthetic jelly Surgical: - chronic stage (lateral internal sphincterotomy)

90. Anal Fissure Treatment: Conservative: anal hygiene / bulk forming agents hot sitz bath local anesthetic jelly Surgical: chronic stage (lateral internal sphincterotomy)

91. THANK YOU