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ANAL FISSURE
LOCATION
Midline posteriorly 90%. Midline anteriorly
ETIOLOGY
Hard fecal mass Ischemia Incorrectly performed operations for
haemorrhoids in which too much skin is removed. Inflammatory bowel disease (crohns disease). Sexually transmitted diseases.
PATHOLOGY
Anal fissure occurs in the stratified sensitive
epithelium of lower half of anal canal so pain is the most prominent symptom.
Inflamed indurated margins Ulcer is canoe shaped & at the inferior extremity
there is a tag of skin known as a SENTINEL PILE (it guards the fissure). Spasm of internal sphincter. Infection, abscess & fistula formation may result. Common cause is crohns disease.
CLINICAL FEATURES
PAIN
Sharp agonizing pain on defecation in lower half of anal canal lasting for an hour.
BLEEDING
DISCHARGE
EXAMINATION
Sentinel skin tag can usually be displayed. Tightly closed puckered anus. By gently parting the margins of anus, the lower
end of fissure can be seen. Digital examination should be avoided because of intense pain but if fissure is not seen then 5 % xylocaine is applied & necessary examination should be done. Characteristic crater feels like a vertical buttonhole can be palpated.
DIFFERENTIAL DIAGNOSIS
Carcinoma of anus. Multiple fissures as a complication of skin
disease e.g. scratching, herpes, HIV. Tuberculous ulcer. Proctalgia fugax.
TREATMENT
The object of all treatment is to obtain complete relaxation of internal sphincter.
canal. Diltiazem, calcium channel blocker. Botulinum toxin. Laxative to ensure stool softner. Anal dilators with xylocaine are rarely effective.
SURGICAL TREATMENT
Under general anesthesia the index & middle finger of each hand are inserted into anus & carefully pulled apart .Care should be taken to prevent the over stretching of anal sphincter.
Follow-up
Sitz baths, analgesics, and stool bulking
agents are used in follow-up care. Frequent follow up visits within the first few weeks help ensure proper healing and wound care. Digital examination findings can help distinguish early fibrosis. Wound healing usually occurs within 6 weeks
Complications
Early postoperative
Delayed postoperative
Recurrence Incontinence (stool) Anal stenosis: The healing process causes fibrosis of
the anal canal. Delayed wound healing: Complete healing occurs by 12 weeks unless an underlying disease process is
HAEMORRHOIDS
TYPES
INTERNAL HEMORRHOIDS It is the dilatation of internal venous plexus with displaced anal cushion lie above dentate line covered by anal mucosa. EXTERNAL HEMORRHOIDS It lies below the dentate line, external to anal orifice covered by skin. INTEROEXTERNAL HEMORRHOIDS Both varieties are present.
INTERNAL HEMORRHOIDS
ETIOLOGY
hemorrhoidal veins. Constriction of superior hemorrhoidal tributaries during defecation. Absence of valves in superior rectal veins. Straining during constipation. Straining at micturition. Pregnancy.
Internal hemorrhoids are arranged in three groups at 3,7 &11 Oclock position with patient in lithotomy position. Each hemorrhoid is divided into 3 parts 1.Pedicle 2.Internal hemorrhoid 3.External hemorrhoid
CLINICAL FEATURES
Symptom
Sign
Inspection Digital rectal examination Proctoscopy Sigmoidoscopy
COMPLICATIONS
Profuse hemorrhage Strangulation Thrombosis Ulceration Gangrene Fibrosis Suppuration Pyle phlebitis
TREATMENT
Medical Treatment
90% can be treated with conservative medical and conservative non-surgical measures. Fiber, avoid constipation, diarrhea if causative. Lidocaine jelly, NTG cream
Active Treatment
INJECTION This is ideal for 1st degree hemorrhoids. Through a proctoscope 3-5ml of 5% phenol in almond oil is injected.
BARRON BANDING Useful in 2nd degree hemorrhoid. Slipping of tight elastic band on base of pedicle. Only 2 hemorrhoids should be banded at each session.
CRYOSURGERY Liquid nitrogen is applied at -196C which causes coagulation necrosis of piles. PHOTOCOAGULATION Local application of infrared coagulation.
OPERATION
INDICATION Third degree hemorrhoid. Second degree not cured by bandig Fibrosed hemorrhoid Interoexternal hemorrhoid
PREOPERATIVE PREPARATION
OPEN TECHNIQUE
Lithotomy position
CLOSED TECHNIQUE
Prone jack-knife position HILL-FURGUSON retractor is used.
ENDOSTAPLING TECHNIQUE
It is a new technique using stapling gun. Excision of strip of mucosa & submucosa above
dentate line. Veins are incorporated in excision. Activation of gun repair the cut mucosa & submucosa by stapling edges together. This is a quick, less painful & less traumatic procedure.
Twice daily hot sitz bath Bulk laxative to take twice daily Analgesics Application of dry dressing DRE should be performed in follow up after 3- 4 weeks. If there is evidence of stenosis, pt is encouraged to use dilator.
EARLY Pain Retention of urine Reactionary hemorrhage LATE Secondary hemorrhage Anal fissure Anal stricture Incontinence
EXTERNAL HEMORRHOIDS
THROMBOSED EXTERNAL HEMORRHOIDS