ANAL AND PERIANAL CONDITIONS surgery .pptx

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1. EMNET ADANE (MD) 1 BENIGN PERIANAL CONDITIONS DEPARTMENT OF SURGERY

2. Anal and perianal conditions 2 Includes: Rectal prolapse Hemorrhoid Anal fissure Perianal abscess Fistula in ano DEPARTMENT OF SURGERY

3. Anatomy of the rectum and anal canal 3 Anatomic points of reference 1. Anal verge Distal external boundary of anatomical anal canal Junction between anal and perianal skin 2. The Dentate line Proximal border of the anatomic anal canal is true muco- cutaneous junction 3. Anorectal ring Upper border of the surgical anal canal 1-1.5 cm above the dentate line DEPARTMENT OF SURGERY

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5. ANORECTAL VASCULAR SUPPLY 5 Arterial supply a. Superior rectal artery From inferior mesenteric artery b. Middle rectal artery From internal iliac artery c. Inferior rectal artery From pudendal artery-a branch of internal iliac artery The venous drainage of the rectum parallels the arterial supply. DEPARTMENT OF SURGERY

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7. RECTAL PROLAPSE 7 Rectal prolapse refers to a circumferential protrusion of the rectum through the anus. Classification : Partial thickness (mucosal prolapse ): often associated with hemorrhoidal disease Complete prolapse ( procidentia ) Internal prolapse : occurs when the rectal wall intussuscepts but does not protrude More common in females ( F:M ratio of 6:1) More prevalent with age peak age in 7th decade. DEPARTMENT OF SURGERY

8. Causes 8 Conditions with increased intra-abdominal pressures Constipation Diarrhea BPH COPD Pelvic floor dysfunction Neurologic disorders Lumbo sacral trauma Spinal tumors DEPARTMENT OF SURGERY

9. Pathophysiology 9 Not completely understood 2 theories 1:- It is a sliding hernia through a pelvic floor defect 2:- Holds that prolapse starts as circumferential internal intussusception Progresses as full thickness prolapse through time and straining. DEPARTMENT OF SURGERY

10. Clinical presentation 10 Hx Constipation Fecal incontinence Mucus drainage Sensation of tissue protruding through the anus Sensation of incomplete evacuation Rectal bleeding P/E Protruding rectal mucosa Thick concentric mucosal ring Sulcus noted between anal canal and rectum Solitary rectal ulcer (10-25%) Decreased anal sphincter tone DEPARTMENT OF SURGERY

11. Differential diagnoses 11 Hemorrhoids Rectal polyps Intussusception ( pediatrics) DEPARTMENT OF SURGERY

12. C omplications 12 Incarceration/ strangulation Minor rectal bleeding Anemia Ulceration, incontinence DEPARTMENT OF SURGERY

13. I nvestigations 13 NB: The diagnosis is usually made based on history and physical examination Proctosigmoidoscopy Look for ulceration (10-25%of patients) Inflammation Other colonic problems DEPARTMENT OF SURGERY

14. Treatment 14 Emergency department care Gentle digital pressure reduction If bowel edema present Reduction may be difficult Sedation and LA may aid reduction Sprinkle the prolapse with salt or sugar Emergency resection If strangulated Two categories A. Abdominal procedures B. Perineal procedures DEPARTMENT OF SURGERY

15. Complications of surgical treatment 15 Infection Bleeding Bowel injury Anastomotic leak Bladder and sexual function alteration Constipation/outlet obstruction DEPARTMENT OF SURGERY

16. Hemorrhoids 16 Hemorrhoids are cushions of submucosal tissue located in the anal canal containing; Blood vessels Smooth muscles and Elastic connective tissues . Hemorrhoids are thought to function as part of the continence mechanism and aid in complete closure of the anal canal at rest. Present at 3,7 and 10 o’clock position (commonly) DEPARTMENT OF SURGERY

17. 17 Increase venous engorgement of the haemorrhoidal plexus and prolapse of haemorrhoidal tissue is caused by; Excessive straining, increased abdominal pressure , and hard stools prevalence increases with age (Peak 46-65 years of age) E qual in both sexes High fiber diet reduces prevalence DEPARTMENT OF SURGERY

18. Classification 18 Based on anatomic origin and their position relative to dentate line 1. External hemorrhoids Distal to dentate line Covered by stratified squamous epithelium 2. Internal hemorrhoids Above the dentate line Covered by simple columnar epithelium 3. Mixed Hemorrhoids Confluent internal and external hemorrhoids DEPARTMENT OF SURGERY

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20. Classification of Internal Hemorrhoids 20 Based on degree of prolapse 1 . First degree: confined to anal canal Painless rectal bleeding 2 . Second degree: Prolapse beyond anal verge Spontaneous reduction 3. Third degree: Requires manual reduction 4. Fourth degree Can’t be manually reduced DEPARTMENT OF SURGERY

21. Clinical presentation 21 Common symptoms Bright red painless bleeding Pruritus Swelling Prolapse and discharge Severe anal pain Thrombosis and strangulation Procedures Anoscopy Sigmoidoscopy (if weight loss, change in bowel habits and Tensmus) to R/O Colorectal Ca DEPARTMENT OF SURGERY

22. Treatment 22 Medical measures (conservative measure) High fiber diet (>25gms of fiber per day) Increase fluid intake Topical creams (short term relief) Steroids, LA, antiseptics Avoid constipation/ straining DEPARTMENT OF SURGERY

23. 23 When conservative Rx fails A. Rubber Band Ligation For 2nd and 3rd degree Apply bands above dentate line 1st and 2nd degree Hemorrhoids B . Infrared coagulation C. Injection sclerotherapy D. Cryotherapy E. Laser therapy DEPARTMENT OF SURGERY

24. Anoscopic band ligation 24 DEPARTMENT OF SURGERY

25. Surgical treatment 25 Hemorrhoidectomy Most effective modality of treatment Indications Non surgical treatment fails Grade III and IV with severe symptoms Presence of concomitant anorectal problems e.g. fissure, fistula DEPARTMENT OF SURGERY

26. Complications of Hemorrhoidectomy 26 Urinary retention is common Pain also can lead to fecal impaction. Bleeding, Infection Long-term sequelae of hemorrhoidectomy include incontinence , anal stenosis , and ectropion ( Whitehead's deformity ) DEPARTMENT OF SURGERY

27. Fissure-In-Ano 27 Definition It is a painful vertical defect or laceration in the anoderm Located between dentate line and anal verge Acute anal fissure (<2 months) Chronic anal fissure (>2months ) DEPARTMENT OF SURGERY

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30. 30 Almost always in the posterior midline If located off the midline s uspect serious pathologies Chron’s disease (30-50% of patients) HIV/ AIDS Cancer Leukemia (24% of patients) The frequency is Equal in both sexes DEPARTMENT OF SURGERY

31. 31 Etiology /pathophysiology Exact etiology not known Mostly trauma from hard stool Low fiber diets Chronic diarrhea Prior anal surgery Makes anal canal susceptible for trauma from hard stools. DEPARTMENT OF SURGERY

32. Clinical presentations 32 Symptoms are relatively specific DX can be made on history alone Severe pain during defecation ( burning, cutting or tearing ) Patients become afraid to defecate Bright red blood  70% of patients Scanty (seen on tissue paper or stool surface) Mucous discharge Pruritus DEPARTMENT OF SURGERY

33. 33 Diagnostic procedures Gentle perineal exam with inspection PR examination can be deferred if painful If fissure not easily visualized Anoscopy EUA(Examination Under Anesthesia) facilitates examination DEPARTMENT OF SURGERY

34. 34 Surgical treatment Reserved for Failure of medical RX for acute fissures Chronic fissures 1. Sphincter dilatation (LORD Anal Stretch) 2. Lateral internal sphincterotomy DEPARTMENT OF SURGERY

35. Anorectal Abscess 35 It is suppurative disease of the anus and the rectum . Pyogenic infection of anal glands. DEPARTMENT OF SURGERY

36. 36 Etiology Inflammation of anal glands Commonest cause Crypto glandular theory Closure of ducts Anal gland inflammation Abscess formation If abscess enlarges Escapes the intersphincteric plane Spreads in several directions DEPARTMENT OF SURGERY

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38. Classification (Anorectal abscess) 38 According to perirectal space involved 1. Perianal (commonest) 2. Ischio rectal 3. intersphincteric 4. Submucosal 5. Deep post anal and 6. Supra levator abscess Abscess may involve multiple space (e.g. horse shoe abcess) DEPARTMENT OF SURGERY

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40. Presentation 40 History Slow , gradual onset of pain Constant sensation of pressure / fullness P/E Findings vary depending on site of the abcess Localized swelling , flactuance , tenderness Purulent discharge Indurated mass in the buttock Pelvic mass (identified on PR or PV exam) Supra levator abcess DEPARTMENT OF SURGERY

41. Treatment 41 Requires immediate drainage Antibiotics: not indicated except Extensive cellulitis Valvular heart disease DM Compromised immunity DEPARTMENT OF SURGERY

42. 42 Perianal abcess OPD Mx possible (LA) Cruciate incision Excise skin edges Break all loculations Packing not required Causes discomfort Hinders free drainage Draining catheter may be left DEPARTMENT OF SURGERY

43. 43 Ischio rectal abcess Incise over the area of maximum swelling, pain and flactuance severe throbbing pain is characteristics As close to anal verge as possible Intersphincteric abcess Sphincterotomy overlying the abcess Submucosal abcess Internally excise the mucosa DEPARTMENT OF SURGERY

44. 44 Post anal abcess Drain by a deep posterior midline incision One or more secondary incisions over ischio rectal space (If there is horse shoe extension) Supra levator abcess Identify the origin first If from abdominopelvic disease Trans abdominal or Trans rectal drainage DEPARTMENT OF SURGERY

45. Fistula- In – Ano 45 A fistula is an abnormal communication between two epithelial surfaces. External opening : one on the skin Internal opening : in anal canal or rectum Epidemiology 2-4 fold male predominance Mean age: 40 years DEPARTMENT OF SURGERY

46. 46 Etiology Crypto glandular theory Abcess formation Drains along path of least resistance (forming a fistula) Internal opening: in anal canal or rectum Other possible causes Crohn’s disease Tuberculosis Actinomycosis Rectal/ anal malignancy HIV/AIDS DEPARTMENT OF SURGERY

47. Classification 47 Park’s classification Most common system derived from the crypto glandular hypothesis 4 main sub groups According to the course taken 1. Intersphincteric (70%) Predominant type 2. Trans- sphincteric (25%) 3. Supra sphincteric (5%) 4. Extra sphincteric (1%) DEPARTMENT OF SURGERY

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50. Clinical presentations 50 Acute phase Pain , tenderness , abcess Patients may present electively to OPD Perianal purulent discharge Unexplained perineal or low sacral pain Symptoms of IBD (inflammatory bowel disease) Abdominal pain Loss of weight Diarrhea Rectal bleeding Previous abcess drainage (spontaneous or surgical) DEPARTMENT OF SURGERY

51. Goodsall's rule to identify the internal opening of fistulas in ano 51 DEPARTMENT OF SURGERY

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53. 53 Investigations : Usually Hx &P/E are adequate 1 . Endorectal ultrasound 2 . Fistulography 3 . MRI: Ix of choice for complex fistula 4 . Anal manometry : Diagnostic procedures EUA: necessary before surgery DEPARTMENT OF SURGERY

54. 54 Surgical Treatment 1. Fistulotomy/ Fistulectomy for fistula in-ano 2. Seton placement for high fistula in-Ano DEPARTMENT OF SURGERY

55. 55 THANK YOU! DEPARTMENT OF SURGERY