Professional Documents
Culture Documents
By
EDN
Anorectal Anatomy
Arterial Supply
Nerve Supply
Inferior rectal A
middle rectal A
Sympathetic: Superior
hypogastric plexus
Venous drainage
Inferior rectal V
middle rectal V
hemorrhoidal 3
complexes
: Parasympathetic
S234 (nerviergentis
: Pudendal Nerve
Motor and sensory
L lateral
R antero-lateral
R posterolateral
Anal canal
Lymphatic drainage
Above dentate: Inf. Mesenteric
Below dentate: internal iliac
Anal verge
Haemorrhoids
Back Ground
L lateral
R anterior
R posterior
This combination
is only in 19%
Haemorrhoids
Pathogensis
Abnormal haemorrhoids are dilated cushions of arteriovenous
plexus with stretched suspesory fibromuscular stroma with
prolapsed rectal mucosa
3 main processes: 1. Increased venous pressure
2. Weakness in supporting fibromuscular stroma
3. Increased internal sphincter tone
Risk Factors
Habitual
Pathological
1.
2.
3.
4.
5.
6.
7.
8.
1.
2.
3.
4.
5.
6.
7.
Haemorrhoids
:Classification
Origin in relation to Dentate line
1.
2.
3.
Internal: above DL
External: below DL
Mixed
Haemorrhoids
Clinical assessment
History ( Full history required)
Examination
Haemorrhoid directed:
Pain
acute/chronic/
cutaneous
Lump
acute/ sub-acute
Prolapse define grade
Bleeding fresh, post defecation
Pruritis and mucus
Local
General GI:
Digital:
Inspect for:
Lumps, note colour and
reducability
Fissures
Fistulae
Abscess
Masses
Character of blood and mucus
Haemorrhoids
:Investigations
The diagnosis of haemorrhoids is based on
clinical assessment and proctoscopy
Complications
1.
2.
3.
4.
Ulceration
Thrombosis
Sepsis and abscess formation
Incontinence
Thrombosed
internal
haemorrhoids
Thrombosed
external
haemorrhoids
Haemorrhoids
:Internal H. Treatment
Conservative Grade 1&2
Measures
Dietary modification: high fibre diet
Stool softeners
Bathing in warm water
Topical creams NOT MUCH VALUE
Minimally
invasive
injection sclerotherapy
Laser photocoagulation
Cryotherapy freezing
Stapled haemorrhoidectomy
Surgical
Indications:
1.
Failed other treatments
2.
Severely painful grade 3&4
3.
Concurrent other anal conditions
4.
Patient preference
Haemorrhoids
:External H. Treatment
Enucleate under LA or GA
Conservative measures
60%
5%
Ischiorectal
20%
Intersphincteric
suprasphincteric
Trans-sphincteric
extrasphincteric
Perianal Abscess
Clinical presentation
Abscess
Clinical presentation
Perianal
Ischio-rectal
Intersphincteric
Supralevator
Peri-anal Fistula
Clinical presentation
Presentation:
External openings
Purulent discharge
Blood
Perianal pain
Godsalls law
Anterior: drain straight
Posterior: drain curved to anorectal
midline
Perianal Abscess
Management
Aim:
Perianal
Ischio-rectal
Intersphincteric
Supralevator
Treatment
Incision and drainge de-roof cavity
pack with gauze and iodine
IV AB, sitz bath tid, laxitives and anlgesia
F/U for fistula
I&D through interspgincteric plane.
Treat the underlying cause
Perianal fistula
Managment
Aim:
Define anatomy
Eliminate tract
preservation of sphincter function
Fistula
Perianal
Treatment
Fistulotomy vs fistulectomy