ANAL & PERIANAL DISEASE (PART 2)

Pictures of surgical procedures are from youtube video. to watch full video, go to the link copied on the "references" slide.

1. ANAL & PERIANAL DISEASE (PART 2) NUR HANISAH BINTI ZAINOREN

2. Contents ANAL FISSURE PRURITUS ANI ANORECTAL ABSCESS FISTULA-IN-ANO HIDRADENITIS SUPPURATIVA ANAL WARTS ANAL INTRAEPITHELIAL NEOPLASIA (ANI ) ANAL STENOSIS MALIGNANT TUMORS

3. ANAL FISSURE A longitudinal split in the anoderm of the distal anal canal, which extends from the anal verge proximally towards, but not beyond the dentate line (SYN: FISSURE-IN-ANO)

4. Superficial, small but distressing lesion Fissure ends below the dentate line Commonly occurs in the midline, posteriorly or anteriorly

5. Causes Trauma  strained evacuation of a hard stool (acute)  Repeated passage of diarrhea (less common) Posterior anal fissure  perhaps relates to the exaggerated shearing forces acting at that site during defecation Anterior anal fissure  common in females (10:1) due to lack of support to pelvic floor (following vaginal delivery)

6. Clinical features Constipation Severe anal pain on defecation Passage of fresh blood (bright red) Chronic fissure ; characterized by: Hypertrophied anal papilla internally & sentinel tag exernally (both consequent upon attempts at healing and breakdown) Between them, lies the slightly indurated anal ulcer overlying the fibres of the internal sphincter (felt as button like depression) Patient may have itching secondary to irritation from the sentinel tag Discharge from the ulcer or asst. intersphincteric fistula

7. Sentinel tag ‘Sentinel’ means guard Commonly associated with fissure-in- ano of chronic type, wherein, in the lower part of fissure, skin enlarges and appears like guarding the fissure Can cause perianal haematoma , abscess formation, and discomfort Chronic fissure is treated along with excision of sentinel pile

8. Differential diagnosis Carcinoma anal canal Inflammatory bowel disease Venereal diseases Anal chancre Tuberculous ulcer Proctalgia fugax

9. Treatment Conservative management: Adequate fluid intake (6-8 glasses of liquid) Fiber rich diet (vegetables, fruits, brown rice) Bulk forming agents ( psyllium husk, bran) Stool softeners (lactulose) Local anaesthetic agents (lignocaine 5%) Pharmacological agents (commonly nitric oxide donors) Reducing spasm to relieve pain Increase vascular perfusion to promote healing Sitz bath Operative measures: Lateral anal sphincterotomy Anal advancement flap

10. Lateral Anal Sphincterotomy

11. Lateral Anal Sphincterotomy

12. Lateral Anal Sphincterotomy

13. PRURITUS ANI Intractable itching in and around the anus

14. Common , embarrasing condition S kin is reddened, hyperkeratotic , cracked & moist Causes: Poor hygiene Anal discharge (due to fissure/fistula/piles/warts/polyps ) Trichomonas vaginalis infection (females) Parasites Epidermophytosis Allergic cause Skin diseases -Dermatitis/psoriasis Diabetes mellitus Psychological cause

15. Treatment Proper cause should be assessed and treated Symptomatic treatment includes: Hygiene measures : toilet paper  cotton wool; soap water ; rubpat-dried ; cotton underwear; calamine lotion; shaving Hydrocortisone : only in patients with dermatitis Strapping of the buttocks *Surgery is only indicated if there’s a lesion of the anorectum that is thought to initiate/contribute to the pruritus

16. ANORECTAL ABSCESS infected cavity filled with pus found near the anus or rectum

17. Usually produces a painful, throbbing swelling in the anal region Patient often has swinging pyrexia Subdivided according to anatomical site into perianal, ischiorectal , submucous and pelvirectal

18. Acute sepsis in the region of the anus is common Underlying conditionts include F istula-in- ano (most common) Crohn’s disease Infected hematoma Foreign body/trauma Diabetes Immunosuppression Treatment drainage of pus + antibiotics

19. FISTULA-IN-ANO Fistula-in- ano /anal fistula is a chronic abnormal communication which runs outwards from the anorectal lumen (the internal opening) to an external opening on the skin of the perineum or buttock or vagina (women, rare)

20. May be found in specific conditions like: Crohn’s disease Tuberculosis Lymphogranuloma venereum Actinomycosis Rectal duplication Foreign body M alignancy

21. Types of Anal Fistula

22. Clinical assessment: Determine the: Site of internal opening Site of external opening Presence of secondary extensions Presence of other conditions complicating the fistula Goodsall’s rule used to indicate the likely position of the int. opening according to position of the ext. opening (HELPFUL BUT NOT INFALLIBLE!) Probing in an awake patient is painful, unhelpful, dangerous

23. Full examination under anaesthesia should be repeated before surgical intervention To demonstrate the site of internal opening: Instillation of hydrogen peroxide via the external opening Gentle use of probes and a finger in the anorectum  usually delineates primary and seconday tracks & their relation to the sphincter

24. fistulotomy

25. fistulectomy

26. Setons

27. HIDRADENITIS SUPPURATIVA A chronic suppurative condition of apocrine gland-bearing skin and is a source of considerable physical and psychological morbidity

28. Presentation Not seen before puberty, rare after 4 th decade of life 3x more common in women than men Obesity is a common association Lesion begin as multiple raised boils, with recurrent lesion within the same area leading to sinus tract formation Treatment In early stages, general measures: Weight reduction Antiseptic soaps Surgical intervention ranges from simple I&D to radical excision of all apocrine gland-bearing skin  req. closure by skin graft/rotation flap

29. ANAL WARTS ( CONDYLOMATA ACCUMINATA ) Most common sexually transmitted anal disease.

30. It is caused by Human Papilloma Virus(HPV) Increase incidence in: sexual promiscuity (esp. anal intercourse) immunocompromised individual (HIV-infected individuals, transplant recipients)

31. Presentation Many are asymptomatic Pruritus, discharge, bleeding & pain are usual presenting complaints Penile warts or female genital warts may be present Treatment Local application of 25% podophyllin cream Surgical excision under local/regional/general anaesthesia

32. ANAL INTRAEPITHELIAL NEOPLASIA (ANI) Multifocal virally induced dysplasia of the perianal /intra-anal epidermis which is aassociated with HPV

33. Prevalence: <1% of the population, with a rising incidence esp. in area where anoreceptive intercourse & HIV are prevalent At-risk group: HIV patients Immunocompromised patients Patients with extensive anogenital condylomata Women with h/o other genital intraepithelial neoplasia (VIN & CIN)

34. ANAL STENOSIS

35. May be spasmodic or organic Spasmodic: Anal fissure causes spasm of the anal sphincter Organic: Postoperative stricture ( hemorrhoidectomy ) Irradiation stricture ( chemoradiation for anal carcinoma/ pelvic tumors) Senile anal stenosis Inflammatory bowel disease (Crohn’s/UC) Neoplastic Treatment: Biopsy must be taken to rule out malignancy Can usually be managed by regular dilatation Severe anal stenosis may require an anoplasty

36. MALIGNANT TUMOR Rare! Accounts for <2% of all large bowel cancers

37. Rare Incidence rate is 0.65 per 100,000 Usually a squamous cell carcinoma Associated with HPV More prevalence in patient with HIV infection May affect anal verge or anal canal Lymphatic spread is to inguinal LN Treatment: chemotherapy Major ablative surgery is required if the above fails

38. R eferences Bailey & Love’s Short Practice of Surgery, 26 th Edition SRB’s Manual of Surgery, 4 th Edition Videos: https :// www.youtube.com/watch?v=JnsWuMJJysg ( fistulotomy ) https:// www.youtube.com/watch?v=PsYnEXGxf-M&oref=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DPsYnEXGxf-M&has_verified=1 ( fistulectomy ) https:// www.youtube.com/watch?v=qn2_Krasyr0 (anal fissure)

39. THANK YOU