Anal Canal


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Anal Canal

  1. 1. Anal canal <br />Dr. Tanuj Paul Bhatia<br />
  2. 2. Anatomy <br />Most distal portion of the alimentary canal. <br />Extends for a distance of about 3 cm from the anorectal ring to the hairy skin of the anal verge.<br />Anus provides continence for flatus and faeces.<br />
  3. 3.
  4. 4. Internal hem. plexus<br />Anal crypts and columns<br />Dentate line<br />Int. sphincter<br />Anal gland<br />White line<br />External sphincter<br />
  5. 5. Nerve supply<br />Below the dentate line, cutaneous sensations conveyed by afferent fibers in the inferior rectal nerves.<br />Above the dentate line : parasympathetic fibres<br />
  6. 6. Blood supply<br />Arterial supply :<br />The middle rectal arteries arise from the internal iliac arteries.<br />The inferior rectal arteries, branches from the internal pudendal arteries.<br />Venous drainage : <br />Above dentate line : Int. hem. plexus sup rectal vein  Inf. Mesenteric vein<br />Below dentate line : Ext. hem. Plexus <br /><ul><li>Middle rectal vein Int. iliac vein OR
  7. 7. Inf. Rectal vein  pudendal vein  Int. iliac vein </li></li></ul><li>Sphincter complex<br />External sphincter<br />Extension of levatorani around anorectum<br />Voluntary sphincter<br />Supplied by pudendalnerver<br />3 compnents : <br />Subcutaneous <br />Superficial <br />Deep <br />
  8. 8. Internal sphincter<br />Involuntary sphincter<br />Innervated by autonomic nervous system<br />Formed by extension of rectal musculature<br />
  9. 9. Formation of anal sphincters<br />
  10. 10. Fecal incontinence<br />The principal function of the anal canal is the regulation of defecation and maintenance of continence.<br />Evaluated by manometry, defecography and electromyography. <br />
  11. 11. causes<br />
  12. 12. Management of fecal incontinence<br />
  13. 13. hemorrhoids<br />
  14. 14.
  15. 15. Degree or stagewise classification<br />1st degree: bleeding<br />2nd degree: protrusion but spontaneous reduction<br />3rd degree: protrusion that requires manual reduction<br />4th degree: irreducible protrusion<br />
  16. 16. External<br />1st degree<br />2nd degree<br />3rd degree<br />4th degree<br />
  17. 17. Treatment options<br />Slerotherapy<br />Rubber band ligation<br />Open hemmorhoidectomy<br />Closed hemmorhoidectomy<br />Stapled hemmorhoidectomy<br />
  18. 18. Band ligation<br />
  19. 19. Hemmorhoidectomy<br />
  21. 21. Thrombosed external hemorrhoid<br />DISEASE<br />
  22. 22. ANAL FISSURE OR FISSURE-IN-ANO<br />Linear ulcer of lower half of anal canal<br />Posterior fissure is most common<br />Anterior fissures commoner in women than men<br />Fissure in any other location : suspect <br />Crohn’s disease<br />Hydradeinitissuppuritiva<br />STDs <br />
  23. 23. Posterior fissure-in-ano<br />
  24. 24. pathogenesis<br />passage of large, hard stools, which may be the initiating factor; <br />inappropriate diet; <br />previous anal surgery; <br />childbirth; and <br />laxative abuse. <br />
  25. 25. symptoms<br />With defecation, the ulcer is stretched, causing pain and mild bleeding.<br />
  26. 26. types<br />Acute fissure in ano<br />Chronic fissure in ano<br />
  27. 27. Acute fissure in ano<br />Short history<br />Painful<br />No sentinel pile on examination<br />Managed conservatively<br />
  28. 28. Chronic fissure in ano<br />Recurrent acute fissure<br />Associated with sentinel pile<br />Can be treated conservatively initially but may require surgery<br />Sentinel pile : <br /> a skin tag formed due to chronic inflammation and fibrosis<br />
  29. 29.
  30. 30. treatment<br />Non surgical<br />Surgery <br />AIM: To increase the blood supply to promote healing of the ulcer/fissure<br />
  31. 31. Non surgical treatment<br />Stool bulking agents<br />Hot tub baths/ Sitz bath<br />Local ointments<br />Lignocaine<br />Nitroglycerine<br />Dietary modifications<br />Botox injections<br />
  32. 32. surgical<br />Sphincterotomy<br />Internal anal sphincter is cut to relieve the spasm and in turn increase blood supply to the fissure<br />Midline sphincterotomies cause key hole defects, hence lateral sphincterotomy is done.<br />2 types : <br />Open<br />Closed <br />
  33. 33. Open sphincterotomy<br />
  34. 34. Closed sphincterotomy<br />
  35. 35. Anal sepsis and fistulae<br />Anorectalabcess – acute form of anal sepsis<br />Fistula in ano – chronic form of the disease process<br />Anal fistula : communication between an internal opening in the anal canal and an external opening through which an abscess drained.<br />
  36. 36. etiology<br />Infection of obstructed anal glands : Most common cause<br />Trauma<br />Foreign body<br />Tuberculosis<br />Actinomycosis<br />Inflamatory bowel disease<br />
  37. 37. classification<br />
  38. 38. treATMENT<br />
  39. 39. Anorectalabcess<br />
  40. 40. Perianal abscess<br />Results frtom suppuration of anal gland or suppuration of a thrombosed external pile<br />Lies in the region of subcutaneous portion of external sphincter<br />
  41. 41. Clinical features <br />Severe pain in perianal region<br />Difficulty in sitting<br />Tender smooth and soft swellling in the perianal region<br />
  42. 42. treatment<br />Sitz bath<br />Antibiotics<br />Drainage under GA<br />
  43. 43. Ischiorectalabcess<br />Due to extension of intermuscularabcess through external sphincter<br />Can be blood born as well<br />Fat in fossa more prone for infection as it is least vascularized<br />Both these fossa are connected  one fossa infection may lead to the infection on other side HORSE SHOE ABCESS<br />
  44. 44. Clinical features<br />Tender, indurated, brawny swelling in the skin over ischiorectalfossa<br />Fever<br />Swelling is not well localized so it is difficult to elicit fluctuation.<br />
  45. 45. treatment<br />Cruciate incision and drainage<br />Pus for c/s<br />Look for any internal opening (for presence of internal fistula)<br />
  46. 46.
  47. 47. Submucousabcess<br />Occurs above the dentate line <br />Can be drained with a sinus forceps through proctoscope<br />
  48. 48. Fistula in ano<br />Etiology <br />Cryptoglandular sepsis(most common)<br />Trauma<br />Crohn’s disease<br />Malignancy<br />Radiationtuberculosis,actinoymycosis<br />
  49. 49. Clinical features<br />Persistent drainage from internal or external opening<br />Indurated tract can be palpable on per rectal examination .<br />External opening easily found but finding the internal opening can be a challenge<br />
  50. 50. Goodsall’s rule<br />‘In general, fitulas with external opening anteriorly connect to internal opening by a short,radial tract.’<br />Fistulas with external opening posteriorly track in curvilinear fashion to posterior midline.<br />EXCEPTION : anterior external opening >3cm from anal verge  usually follow curved track to posterior midline<br />
  51. 51.
  52. 52. Classifications of fistula in ano<br />Park’s classification<br />High and low fistula in ano<br />Simple and complex fistula in ano<br />
  53. 53. Park’s classification<br />Intersphincteric<br />Transsphincteric<br />Suprasphincteric<br />Extrasphincteric<br />
  54. 54. Special investigations<br />Trans rectal ultrasound (TRUS)/ Endoanal ultrasound<br />Fistulogram<br />MRI<br />
  55. 55. Surgical management<br />Fistulotomy<br />Fistulectomy<br />Setons<br />
  56. 56. fistulotomy<br />‘Laying open of the fistula tract from its termination to source’<br />Applied mainly to intersphincteric and transphincteric fistula involving less than 30% of voluntary muscle.<br />Staged sphincterotomy : part of sphincter is divided and rest tied upon by a seton.<br />
  57. 57. fistulectomy<br />Coring out of the fistula<br />
  58. 58.
  59. 59. setons<br />Latin for Bristle<br />Loose and tight setons : depending upon the intent of cutting through the muscle.<br />After tying, these are tightened in intervals of weeks.<br />‘Cheese wire cutting through ice’<br />They gradually cut through the muscles without springing them apart<br />
  60. 60. Staged fistulotomy<br />
  61. 61. Recent advances<br />Advancement flaps<br />Tissue glues<br />
  62. 62. Pilonidal sinus(jeep bottom)<br />Pilus= hair , nidus = nest<br />Of infective origin<br />Occurs in sacral region between the buttocks<br />Other sites : umbilicus, web spaces of fingers(in barbers)<br />
  63. 63. pathology<br />Hair penetrate skin causing dermatitis and infection<br />Persistent infection leads to sinus formation<br />Primary sinus : midline<br />Secondary sinuses : paramedian<br />
  64. 64.
  65. 65. Clinical features<br />Serosanguinous or purulent discharge<br />Throbbing and persistent pain<br />Sometimes tender swelling in the midline<br />Tufts of hair may be seen in the opening of sinus<br />
  66. 66. treatment<br />Excision of the sinuses<br />Laying open the sinus<br />Z- plasty<br />Rotation flaps<br />Bescom’s operation<br />Karydaki’s operation<br />
  67. 67. Anal intraepithelial neoplasia<br />Virally induced dysplasia<br />Risk factors : anoreceptive intercourse and HIV<br />Usually patients are asymptomatic<br />Based on degree of dysplasia : AIN I, AIN II, and AIN III<br />AIN II and III have chances of progressing to invasive carcinoma<br />
  68. 68. Clinical features<br />30%  asymptomatic<br />Suspicious areas are raised, scaly, white, erythematous, pigented or fissured.<br />
  69. 69. management<br />Multiple mapping biopsies<br />Excision followed by colostomy or flaps<br />Topical imiquimod or retinoids have some effect on progression of diesease.<br />
  70. 70. Non malignant strictures<br />Spasmodic : due to anal fissure.<br />Organic : <br />Postoperative<br />Irradiation stricture<br />Senile anal stenosis<br />Lyphogrnulomainguinale<br />Inflamatory bowel disease<br />Endometriosis<br />
  71. 71. Clinical features<br />Increasing difficulty in defecation<br />‘Pipe stem’ stools.<br />Stricture can be palpated as annular or tubular on DRE.<br />
  72. 72. treatment<br />Dilatation by bougies.<br />Anoplasty.<br />Colostomy.<br />Rectal excision and coloanalanastomosis.<br />
  73. 73. Malignant tumors<br />Below dentate line : SCC<br />Above dentate line : basaloid, cloacogenic or transitional carcinomas.<br />
  74. 74. Squamous cell carcinoma<br />Risk factors : <br />HPV infection<br />AIN<br />Immunosuppression<br />
  75. 75. Clinical features<br />Pain<br />Bleeding<br />Pruritus<br />Fecal incontinence as a result of sphincter invasion.<br />Palpable as indurated, irregular, tender ulcers.<br />
  76. 76.
  77. 77. management<br />Primary treatment : chemoradiotherapy<br />CMT(combined modality treatment)<br />5-FU with mitomycin C or cisplatin<br />Resection indicated in <br />Small marginal tumors<br />Persistent or recurrent disease  followed by colostomy<br />
  78. 78. THANK YOU<br />