Anal Rectal Diseases

Anal AbscessAnal CancerAnal FissureAnal Warts Cancer of the AnusCancer of the RectumCondylomaCryptitisEnlarged PapillaeFecal IncontinenceFissureFistula-in-ano

HemorrhoidsLevator SyndromePilonidal CystPolypsProcidentiaProctalgia FugaxProctitisPruritus AniRectal ProlapseRectoceleWarts Venereal

Anorectal Anatomy

Anal verge

Anal canal

Arterial Supply

Inferior rectal A middle rectal A

Venous drainage

Inferior rectal V middle rectal V

3 hemorrhoidal complexes

L lateral

R antero-lateral

R posterolateral

Lymphatic drainage

Above dentate: Inf. Mesenteric

Below dentate: internal iliac

Nerve Supply

Sympathetic: Superior hypogastric plexus

Parasympathetic:

S234 (nerviergentis

Pudendal Nerve:

Motor and sensory

External

Internal

•Anoderm•Swell, discomfort, difficult hygiene

•Pain?-> Thrombosed

•Pain?-> painless•Bright red bleeding•Prolapse associated with defecation

Anatomy

HaemorrhoidsBack 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

• But can be found anywhere in anus• Prevalence is 4%• Miss labelling by referring

physicians and patients is common

This combination is only in 19%

3 main processes: 1. Increased venous pressure 2. Weakness in supporting fibromuscular

stroma 3. Increased internal sphincter tone

Risk Factors Habitual Pathological

1. Constipation and straining2. Low fibre high fat/spicy diet3. Prolonged sitting in toilet4. Pregnancy5. Aging6. Obesity7. Office work8. Family tendency

1. Chronic diarrhea (IBD)2. Colon malignancy3. Portal hypertension4. Spinal cord injury5. Rectal surgery6. Episiotomy7. Anal intercourse

HaemorrhoidsPathogensis

Abnormal haemorrhoids are dilated cushions of arteriovenous plexus with stretched suspesory fibromuscular stroma with

prolapsed rectal mucosa

HaemorrhoidsClassification:

Origin in relation to Dentate line Degree of prolapse through anus

1. Internal: above DL2. External: below DL3. Mixed

•1st: bleed but no prolapse•2nd: spontaneous reduction•3rd: manual reduction•4th: not reducable

A:Thrombosed externalB:First-degree internal

viewed through anoscopeC:Second-degree internal

prolapsed, reduced spontaneously

D:Third-degree internal prolapsed, requiring manual reduction

E:Fourth-degree strangulated internal and thrombosed external

Reference : Sabiston Textbook of Surgery, 18th Edition

HaemorrhoidsClinical assessment

History ( Full history required) ExaminationHaemorrhoid directed:•Pain acute/chronic/ cutaneous•Lump acute/ sub-acute•Prolapse define grade•Bleeding fresh, post defecation•Pruritis and mucus General GI:•Change in bowel habit•Mucus discharge•Tenasmus/ back pain•Weight loss •Anorexia•Other system inquiry

Local•Inspect for:

–Lumps, note colour and reducability–Fissures–Fistulae–Abscess

•Digital:–Masses–Character of blood and mucus

•Perform proctoscopy and sigmoidoscopy

General abdominal examination

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

suspected

The diagnosis of haemorrhoids is based on clinical assessment and proctoscopy

Further investigations should be based on a clinical index of suspicion

HaemorrhoidsInvestigations:

Thrombosed internal haemorrhoids

Thrombosed external haemorrhoids

Complications1. Ulceration2. Thrombosis3. Sepsis and abscess formation4. Incontinence

HaemorrhoidsInternal H. Treatment :

Conservative Measures

Grade 1&2• 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 treatments2. Severely painful grade 3&43. Concurrent other anal conditions4. Patient preference

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

HaemorrhoidsExternal H. Treatment :

Perianal Fistula and AbscessPerianal 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%

5%

Ischiorectal 20%

Intersphincteric

Trans-sphincteric extrasphincteric

suprasphincteric

Pathophysiology

Infection & suppuration

abscess formation

Anal crypts obstruction

Glandular secretion stasis

Perianal Abscess

Perianal AbscessClinical presentation

Abscess Clinical presentationPerianal •Perianal pain, discharge (pus) and fever

•Tender, fluctuant, erythematous subcutaneous lump

Ischio-rectal •Chills, fever, ischiorectal pain•Indurated, erythematous mss, tender

IntersphinctericSupralevator

•Rectal pain, chills and fever, discharge•PR tender. Difficult to identify are. EUA needed

Peri-anal FistulaClinical 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 lawAnterior: drain straight

Posterior: drain curved to anorectal midline

Perianal AbscessManagementAim: adequate drainage of abscess

preservation of sphincter function

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

Abscess TreatmentPerianal •Incision and drainge de-roof cavity

•pack with gauze and iodine•IV AB, sitz bath tid, laxitives and anlgesia•F/U for fistula

Ischio-rectal

IntersphinctericSupralevator

•I&D through interspgincteric plane.•Treat the underlying cause

Perianal fistulaManagmentAim: Define anatomy

Eliminate tractpreservation of sphincter function

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

Fistula TreatmentPerianal •Fistulotomy vs fistulectomyTrans/Extra/Supra sphincteric

•Complex treatments using seton

Anal Fissure Linear tears in the anal mucosa exposing the internal sphincter 90% are posterior Caused mainly by trauma ( hard Stool). Followed by increased

sphincter tone and ischemia. Other causes: IBD, Ca, Chronic infections

Anal Fissure Clinical Assessment

Acute Chronic

•Sever acute pain•Fresh blood spotting•Clean linear tear.

•Pain mild to moderate•More than 6 weeks•Hypertrophied Int.sphincter•Skin tag•Granulation around the edge

Anal Fissure Treatment

Conservative•High fibre diet•Medical sphincterotomy:

–GTN–Ca channel blockers–Butulinum toxins

SurgicalLateral sphincterotomy

Pilonidal SinusPathogenesis:A sinus tract at natal cleft resulting from: Blockage of hair follicle Folliculitis Abscess followed by sinus formation. Hair trapping Foreign body reaction The sinus tract is cephald

Associated with: Caucasians Hirsute Sedentary occupations Obese Poor hygeine

Presentation & Treatment

Also found: umbilicus, finger webs, perianal area

Acute abscess Incision and drainage

Recurrence: 40%

Chronic Pain and discharge

Wide local excision• with primary closure or• closure by secondary intension

Recurrence: 8-15%

HistoryAge

Hemorrhoids- common all ages but are uncommon below the age of

20 years.Perianal haematomata-

occurs at all agesFissure-in-ano-(acute)

quite common in childrenAnorectal abscess-

common between the ages of 20 and 50 years.Pilonidal sinus-

rare before puberty and in people over 40 years.

HistorySex

Hemorrhoids- common in both sexs

Perianal haematomata- occurs at all ages

Fissure-in-ano- common in men

Anorectal abscess- more common in men

Pilonidal sinus- more common in men

Prolapse of rectum- more common in women

HistoryPrincipal symptoms of rectal and anal

conditions:BleedingPainTenesmusChange in bowel habitChange in the stoolDischargepruritis

History - BleedingCan be fresh or altered

Example of altered is melaena Black tarry stool

Recognizable blood may appear in four ways:Mixed with faecesOn the surface of the faecesSeparate from the faeces: after/unrelated to

defaecationOn the toilet paper after cleaning

History - BleedingDiagnosis of anal conditions which

present with rectal bleedingBleeding but no pain:

Blood mixed with stool = ca of colon Blood streaked on stool = ca of rectum Blood after defaecation = hemorrhoids Blood and mucus = colitis

Bleeding + pain = fissure or carcinoma of anal canal

The most common causes of rectal bleeding in patients who visit primary care physicians are hemorrhoids, fissures and polyps.

History – Anal painDiagnosis of anal conditions which

present with painPain alone

Fissure ( pain after defaction) Proctalgia fugax (pain spontaneously at night) Anorectal abscess

Pain with bleeding Fissure

Pain with a lump Perianal haematoma Anorectal abscess

Pain, lump and bleeding Prolapsed haemorrhoids/rectum Carcinoma of the anal canal

Anorectal examinationOne of the most important examinations in a patient with abdominal disease.

Still its the least popular segment of the entire physical examination.

Should not be omitted from your examination, especially in middle-aged and older patient, why? risks missing an asymptomatic carcinooma

Can be done in numerous positions: Left Lateral (Sims’) position. The usual position when the patient

is in bed. Turn patient on to left side with pelvis vertical. Ask patients to draw knees up to chest with buttocks on the side of the couch

The Knee-elbow position. Patient kneeling on couch, resting on elbows, of particular use when palpating the prostate and seminal

The Dorsal Position. This position with the patient lying on the back with right leg flexed is useful when the patient is in severe pain, and movement is contra-indicated. Enables assessment of rectovesical pouch in abdominal emergencies.

Lithotomy. best position for examination but not always available.

Anorectal examinationExternal inspection:

Piles. Skin tags (normal, Crohn's, hemorhoids). Rectal prolapse. Anal fissure. Fistula. Anal warts. Carcinoma. Signs of incontinence, diarrhea.

External inspection (straining): Ask pt. to strain. Rectal prolapse upon straining. Hemorrhoid prolapse. Incontinence. Ask if straining is painful

Anorectal examinationpalpation

Lubricate index finger. Insert finger slowly, assessing external sphincter tone

as enter. Male: palpate prostate [anterior of rectum]:

• Hard nodule (prostate cancer).• Tender (prostatitis).

Female: palpate cervix [anterior of rectum]:• Mass in pouch of Douglas.

Rotate finger, palpating along left, posterior, right walls.

Withdraw finger. Wipe lubricant off pt. Ask if was significant pain during examination. 

Anorectal examinationInspect withdrawn fingertip for:

Blood, melaenaStool colorPusMucous.

Other examination would be systemically preformed and depends on the case you have e.g swelling such as anorectal abscess or ulcers.

Acute Ano-rectal Conditions

Rectal prolapseRectal prolapse is the abnormal movement of the

rectal mucosa down to or through the anal opening.

Mucosal prolapseMucosal prolapse Complete rectal prolapseComplete rectal prolapse

Rectal prolapseMucosal prolapse is more often seen in children

below 3 yrs of age following an attack of diarrhoea or whooping cough , and if it occurs in adult is usually associated with haemrrhoids.

Complete rectal prolapse is seen more commonly in elderly women who have a habit of excessive straining during defecation.

Rectal prolapse is often associated with other conditions such as:

* Pinworms(Enterobiasis) * Cystic fibrosis * Malnutrition and malabsorption (Celiac disease) * Constipation * Prior trauma to the anus or pelvic area

Rectal prolapseSymptoms:The main symptom is a protrusion of a reddish

mass from the anal opening, especially following a bowel movement.

Treatment : * Treating the underlying condition * In children, Conservative treatment * The rectal mass may be returned to the rectum manually * Surgical correction for complete rectal prolapse

Complications * Constipation * Malnutrition or malabsorption * Other complications of underlying condition

ProctitisAn inflammation of the rectum causing discomfort,

bleeding, and occasionally, a discharge of mucus or pus, And the anus may also be involved.

Causes: * Sexually-transmitted diseases(gonorrhea, herpes,

Syphilis ,chlamydia, and lymphogranuloma venereum. * Non-sexually transmitted infections( Beta-hemolytic

streptococcus , Amoebic dysentry, Bilharzial dysentry) *Autoimmune diseases (Ulcerative colitis and crohn’s

disease) * Tuberculous proctitis * AIDS *Radiation Proctitis * noxious agents

ProctitisSymptoms:pain, discomfort rectal bleeding rectal discharge, pus stools, bloody constipation Tenesmus

*Tests:proctoscopy sigmoidoscopy rectal culture

ProctitisTreatment: treatment of the underlying

cause usually cures the problem. Proctitis caused by infection is treated with antibiotics specific for the causative organism. Corticosteroid or mesalamine suppositories may relieve symptoms in Crohn's disease or ulcerative colitis.

Benign tumours of the rectum(POLYPS)A polyp is a lesion that projects into the lumen Polyps are commonly found in vascular organsPolyps bleed easily The rectum and sigmoid colon are common sites of polypsSymptoms and signs of polyps * passage of blood and mucus PR * Rarely obstruction or intussusception

Types of PolypsJuvenile PolypsCommonest form of polyps in children Are red pedunculated spheres lesionsCan occur throughout large bowel but

are most common in the rectum Usually present before 12 years Present with Prolapsing lump or rectal

bleeding Have little malignant potentialTreated by local endoscopic resection

Adenomatous PolypsAre pedunculated lesionsMainly occur in the rectum and sigmoid

colonAre often asymptomatic but may produce

anaemia from chronic occult bleedingMay give rise to crampy pain May secrete mucusHave malignant potentialTreated by colonoscopic polypectomy

Villous PapillomasAre flat, sessile lesions within the rectumSecrete copious amount of mucus

producing spurious diarrhoeaPresent with hypokalemiaSignificant risk of malignant changeTreated by transanal excision of complete

lesionIf lesion is extensive, mucosal

proctectomy and coloanal anastomosis should be done

Familial PolyposisIs an autosomal dominant syndrome diagnosed

when a patient has more than 100 adenomatous polyps

Due to mutation on long arm of chromosome 5May be asymptomatic but bleeding,,

abdominal pain and diarrhoea are all likely symptoms

The risk of devoloping carcinoma is virtually 100%

within 15 yearsThe most appropriate treatment is

panproctocolectomy with ileal pouch-anal anastomosis