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TAIQ.pptx
1. Anorectal Pain & discharge
DR. Saeed Ahmad Al-Shoaib
Surgical Consultan
Surgery MCS General
(Ph-D) Surgical Oncology
College of Medicine
University of Hadramout
(HUCOM)
2. The rectum is 12 – 16 cm long.
It extends from the rectosigmoid junction,
marked by the fusion of the tenia, to the
anal canal, marked by the passage into the
pelvic floor musculature.
3. The anal canal is an invagination of
ectodermal tissue.
The Anorectum develops from fusion of
the rectum and the anal canal.
4. Of anal canal
Anatomy
•The anatomical canal is about 3 cm long
and it extends from the anal verge to the
dentate line
•The surgical anal canal is about 4 cm long
and it extends from the anal verge to the
anorectal junction
5. • Pecten (anoderm) is a hairless part of the
external anal canal that exposed by traction on
the rim of the anus ( lined by keratinized
stratified squamous epithelium )
•The junction between the Pecten and the large
mucosa is known as dentate line .
Of anal canal
Anatomy
6. Anatomy of the anal canal
•The rectum is lined by columnar epithelium
•The transitional zone is lined with cuboidal
epithelium that lines the anal canal from the
columns of morgagni to the dentate line.
•Below the dentate line the anal canal is lined
by squamous epithelium .
8. Differences between the upper and the lower halves of the anal
canal according to the dentate line
Below the dentate line
Above the dentate line
Ectodermal in origin
Endodermal in origin
Lined by squamous epithelium
Lined by columnar epithelium
Under control of the somatic
innervation (sensitive to pain, touch
, temperature)
Under control of the autonomic
nervous sys. (sensitive to stretch )
Drains its venous blood via inferoir
rectal vein into the systemic venous
Drains its venous blood via the sup.
rectal vein to the portal venous
Drains its lymph to the inguinal
lymph nodes.
drains its lymph to the internal iliac
lymph nodes.
9. Surgical Anatomy
•
The blood supply of upper ½ of the anal canal is from the
superior rectal vessels. Where as that of the lower ½ is supply
of the surrounding anal skin the inferior rectal vessels which
derives from the internal pudendal ultimately from the
internal iliac vessels.
10. Surgical Anatomy
•
The lower ½ is lined by squamous epithelium
and the upper ½ by columnar epithelium so
carcinoma of the upper ½ is adenocarcinoma.
Where as that arising from the lower part is
squamous tumour.
11. Surgical Anatomy
•
The lymphatic above the mucocutaneous
junction drain along the superior rectal vessels
to the lumbar lymph nodes, where as below
this line drainage is to the inguinal lymph
nodes.
12. Surgical Anatomy
•
The nerve supply to the upper ½ via
autonomic plexus and the lower ½ is supplied
by the somatic inferior rectal nerves terminal
branch of the pudendal nerve. So the lower ½
is sensitive to the prick needle.
13. Normal Function of the Anorectun
The normal function of the anorectum is storage
and release of intestinal waste products . The
rectum functions mainly as a capacitance
storage vessel.
14. Dysfunction of the Anorectum
•Incontinence:
Continence is maintained through rectal
compliance, ano –rectal sensation, anorectal
reflexes, and anal sphincter function . The nature
and quantity of stool and colonic transit are
important as well . The incidence of fecal
incontinence is difficult to determine because of
underreporting and lack of a standard definition
of the term .
17. Examination of Anus
This requires careful attention to circumstances (couch, light,
gloves). The Sims (left lateral position) is satisfactory. The
examination proceed by;
–
inspection
–
digital examination with index finger
–
proctoscopy
–
sigmoidoscopy
18. Hemorrhoids
Definition : they are engorgement of venous plexi
“cushions” that sit in the anorectal junction.
Could be
External: below the dentate line
Internal: above the dentate line
Commonly situated at :
3 o
’
clock “left lateral”
7 o
’
clock “right posterior”
11 o
’
clock “right anterior”
19. Classification of internal
hemorrhoids
First degree: painless bleeding usually
associated with defecation
Second degree: protrude during defecation
but spontaneously reduce
Third degree: protrude during defecation
and must be manually reduced
Forth degree: permanently prolapsed
23. Signs and symptoms
Painless bright red rectal bleeding
Prolapsing lump
Itching
Mucus discharge
N.B.
sever pain is not typically associated with internal hemorrhoids
but is commonly seen with thrombosed external
hemorrhoids
but if pain is present with absence of strangulation look out for
other conditions “fissure , hematoma, abcess”
24. Assessment and Diagnosis
•
Careful history
Age, type of bleeding, bowel habit
Examination:
•
Abdominal Examination
•
Anorectal Examination
Investigation:
Protoscopy , rigid sigmoidoscopy, colonscopy,Barium enema.
27. Cont. treatment
The definite treatment varies according to
the degree of hemorroids:
1st degree : sclerotherapy
infrared photocoagulation
cryothrapy
2nd degree : rubber band ligation
3rd and 4th degree : hemorrhoidectomy
28. Cont. treatment
Thrombosed external hemorrhoids should be
excised if seen within 48 hr, beyond this time,
conservative therapy with analgesics and sitz
baths is appropriate.
29. Anal Fissure
•
Defined as longitudinal tear in the mucosa and skin of the
anal canal.
•
Commonly posterior midline more common in female than
male. ( tear in squamous epithelium ).
It is the commonest cause of sever anal pain
30. Anal Fissure
•
The acute anal fissure if not treated
becomes chronic
anal fissures. As result
secondary pathological changes
may
occurs:
–
Chronicity
–
A “sentinel” pile
–
Hypertrophied anal papilla
–
Contracture of the anus
–
Suppuration
31. Anal Fissure
•
The acute anal fissure if not treated
becomes chronic
anal fissures. As result
secondary pathological changes
may
occurs:
–
Chronicity
–
A “sentinel” pile
–
Hypertrophied anal papilla
–
Contracture of the anus
–
Suppuration
32. Epidemiology
Acute or chronic tear in the anal canal
usually in posterior midline ( M=F in young
adult)
Anterior fissure is common in Females.
Lateral or multiple fissures should raise
suspicion of trauma, inflammatory bowel
disease ( Chron
’
s disease), lymphoma,
neoplasm or infection.
34. Signs and symptoms
burning pain is associated with defecation.
Bleeding : the blood is usually bright red
and associated with acute fissures.
Physical exam
Acute fissure showing just tear in the anal
mucosa.
Chronic fissure may reveal a sentinel tag or
hypertrophied papilla.
36. Cont. Treatment
Surgical ( with chronic fissure to reduce the
internal sphincter spasm )
- sphincter dilation
- Lateral internal sphincterotomy
37. External Hemorrhoids
•
Perianal Hematoma
•
Due to rupture of dilated anal vein as result of sever straining.
•
Sudden onset of painful lump at the anus.
•
Swelling tense & tender, bluish in colour covered with
smooth shining skin.
38. Treatment
•
Evacuation if the patient come within 48hours
•
If patient come late conservative treatment.
•
If untreated the haematoma undergoes:
–
resolution
–
ulceration
–
suppuration to forms in abscess
–
fibrosis which give rise to skin tag.
39. Perianal Abscess
•
The infection usually starts in one of the crypts of Morgagni
and extends along the related anal gland to the
intersphincteric plane where it forms as abscess.
•
Soon it tracks in various directions to produce different types
of abscesses .
40. Types of Abscess
•
Perianal abscess (60%)
•
Ischiorectal abscess (30%)
•
Sub mucous abscess (5%)
•
Pelvirectal abscess
41. Perianal Abscess
•
Patient with recurrent anorectal abscess always consider
associated underlying diseases such as Crohn’s, UC, rectal
cancer and active TB.
43. Fistula in ano
•
Defined as track lined by granulation tissues, which connects
deeply in the anal canal or rectum and superficially on the
skin around the anus.
•
It usually result from an anorectal abscess.
44. Fistula in ano
•
Anal fistulas have well recognized association with crohn’s
disease, UC, TB, colloid carcinoma of the rectum and lympho
granuloma venercum.
45. Types of Anal Fistulas
•
According to whether their natural opening is below or above the
anorectal ring
•
Low level e.g., subcutaneous, low
anal, sub mucous.
•
High level – open into anal canal
at or above the anorectal ring
e.g.,
high anal, pelvirectal
46. Park’s Classification
•
Inter sphincteric (70%) low level
anal fistula
•
Trans-sphincteric (25%) high
level anal fistula
•
Supra sphincteric fistulae (4%).
•
Extra sphincteric (1%) rare type
include the tract passes outside
all
sphincter muscles to open in
the rectum.
47. Good Sall's Rule
•
Fistulas with external opening in
relation
to the anterior ½ of the anus
tend to be
direct type.
48. Clinical features
•
Persistent discharge which irritates the skin and causes
discomfort at the anus may be associated with pain.
•
External opening may be seen with
palpation the tracks
is often palpable
as cord.
53. Malignant Tumours of the Anal Canal
•
The lesion is usually squamous cell carcinoma.
•
Rarely adenocarcinoma, malignant melanoma or basal cell
carcinoma.
54. Squamous cell carcinoma
•
5% of all anorectal malignancies. Arising from the stratified squamous
epithelium of the lower ½ of the anal canal.
•
It is disease of elderly.
•
Squamous cell carcinoma more common in males.
•
The aetiology of anal carcinoma unknown but chronic irritation or
infection may be predisposing factors.
55. Clinical Features
•
Localized ulcer or raised growth with
irregular ulcerated
surface.
•
History of bleeding.
•
History of pain with discomfort.
•
Tenesmus with incontinence.
•
Discharge.
56. Examination
•
On palpation squamous carcinoma feels hard and woody due to invasion
of perianal tissues.
•
P/R examination may prove impossible because of stenosis or discomfort.
•
Inguinal LN are examined carefully
as they receive lymph from the
lower anal canal and perianal region and may be the
site of
metastasis.
57. Treatment
•
Above the pectinate line
–
Abdomino perineal excision
•
Below the pertinate line
–
local excision.
–
If inguinal LN metastasis present should be removed by block
dissection.
