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Anorectal Disease

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

They are part of the normal


anoderm cushions
They are areas of vascular
anastamosis in a supporting stroma
of subepithelial smooth muscles.
The contribute 15-20% of the normal
resting pressure and feed vital
sensory information .
3 main cushions are found

L lateral
R anterior
R posterior

This combination
is only in 19%

But can be found anywhere in anus


Prevalence is 4%
Miss labelling by referring
physicians and patients is common

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.

Constipation and straining


Low fibre high fat/spicy diet
Prolonged sitting in toilet
Pregnancy
Aging
Obesity
Office work
Family tendency

1.
2.
3.
4.
5.
6.
7.

Chronic diarrhea (IBD)


Colon malignancy
Portal hypertension
Spinal cord injury
Rectal surgery
Episiotomy
Anal intercourse

Haemorrhoids

:Classification
Origin in relation to Dentate line

1.
2.
3.

Internal: above DL
External: below DL
Mixed

Degree of prolapse through anus

1st: bleed but no prolapse


2nd: spontaneous reduction
3rd: manual reduction
4th: not reducable

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:

Change in bowel habit


Mucus discharge
Tenasmus/ back pain
Weight loss
Anorexia
Other system inquiry

Inspect for:
Lumps, note colour and
reducability
Fissures
Fistulae
Abscess
Masses
Character of blood and mucus

Perform proctoscopy and


sigmoidoscopy
General abdominal examination

Haemorrhoids

:Investigations
The diagnosis of haemorrhoids is based on
clinical assessment and proctoscopy

Further investigations should be based on a


clinical
index
of suspicion
Lab: CBC / Clotting
profile/
Group
and save
Proctography: if rectal prolpse is suspected
Colonoscopy: if higher colonic or sinister pathology is
suspected

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

Indicated in failed medical treatment and grades 3&4

injection sclerotherapy

Rubber band ligation

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

If presentation less than 72 hours:

Enucleate under LA or GA

Leave wound open to close by secondary intension

Apply pressure dressing for 24 hours post op

If more than 72 hours:

Conservative measures

Perianal Fistula and Abscess


5%

Perianal abscess almost always arise


from a fistulous tract. It is an infection of
the soft tissue surrounding the anus.
Aetiology & Pathogenesis:
4-10 glands at dentate line.
Infection of the cryptglandular epithelium
resulting from obstruction of the glands.
Ascending infection into the intersphincteric
space and other potential spaces.
Bacteria implicated:
E.Coli., Enterococci, bacteroides
Other causes:
Crohn
TB
Carcinoma, Lymphoma and Leukaemia
Trauma
Inflammatory pelvic conditions (appendicitis)

60%

5%

Ischiorectal
20%

Intersphincteric

suprasphincteric

Trans-sphincteric

extrasphincteric

Perianal Abscess
Clinical presentation
Abscess

Clinical presentation

Perianal

Perianal pain, discharge (pus) and fever


Tender, fluctuant, erythematous subcutaneous
lump

Ischio-rectal

Chills, fever, ischiorectal pain


Indurated, erythematous mss, tender

Intersphincteric
Supralevator

Rectal pain, chills and fever, discharge


PR tender. Difficult to identify are. EUA needed

Peri-anal Fistula
Clinical presentation

Follow 40-60% of perianal


abscess and cryptgland
infections

Presentation:

External openings
Purulent discharge
Blood
Perianal pain

Also associated with:


IBD
Malignancy
TB/ Actinomycosis
Diverticular disease

Godsalls law
Anterior: drain straight
Posterior: drain curved to anorectal
midline

Perianal Abscess
Management
Aim:

adequate drainage of abscess


preservation of sphincter function
Abscess

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

* Preop: full lab evaluation


*Always perform Examination under GA ( EUA) and obtain a biopsy.

Perianal fistula
Managment
Aim:

Define anatomy
Eliminate tract
preservation of sphincter function
Fistula

Perianal

Treatment
Fistulotomy vs fistulectomy

Trans/Extra/Supra Complex treatments using seton


sphincteric
* Preop: full lab evaluation
*Always perform Examination under GA ( EUA) and obtain a biopsy.

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