Anal Canal

1. Anal canal Dr. Tanuj Paul Bhatia

2. Anatomy Most distal portion of the alimentary canal. Extends for a distance of about 3 cm from the anorectal ring to the hairy skin of the anal verge. Anus provides continence for flatus and faeces .

3. White line Dentate line Anal crypts and columns Anal gland Internal hem. plexus Int. sphincter External sphincter

4. Nerve supply Below the dentate line, cutaneous sensations conveyed by afferent fibers in the inferior rectal nerves. Above the dentate line : parasympathetic fibres

5. Blood supply Arterial supply : The middle rectal arteries arise from the internal iliac arteries. The inferior rectal arteries, branches from the internal pudendal arteries. Venous drainage : Above dentate line : Int. hem. plexus sup rectal vein  Inf. Mesenteric vein Below dentate line : Ext. hem. Plexus Middle rectal vein Int. iliac vein OR Inf. Rectal vein  pudendal vein  Int. iliac vein

6. Sphincter complex External sphincter Extension of levator ani around anorectum Voluntary sphincter Supplied by pudendal nerver 3 compnents : Subcutaneous Superficial Deep

7. Internal sphincter Involuntary sphincter Innervated by autonomic nervous system Formed by extension of rectal musculature

8. Formation of anal sphincters

9. Fecal incontinence The principal function of the anal canal is the regulation of defecation and maintenance of continence. Evaluated by manometry , defecography and electromyography.

10. causes

11. Management of fecal incontinence

12. hemorrhoids

13. Degree or stagewise classification 1 st degree: bleeding 2 nd degree: protrusion but spontaneous reduction 3 rd degree: protrusion that requires manual reduction 4 th degree: irreducible protrusion

14. External 1 st degree 2 nd degree 3 rd degree 4 th degree

15. Treatment options Slerotherapy Rubber band ligation Open hemmorhoidectomy Closed hemmorhoidectomy Stapled hemmorhoidectomy

16. Band ligation

17. Hemmorhoidectomy

18. STAPLED HEMORHOIDECTOMY DOUGHNUT OF HEM. TISSUE

19. Thrombosed external hemorrhoid DISEASE

20. ANAL FISSURE OR FISSURE-IN-ANO Linear ulcer of lower half of anal canal Posterior fissure is most common Anterior fissures commoner in women than men Fissure in any other location : suspect Crohn’s disease Hydradeinitis suppuritiva STDs

21. Posterior fissure-in- ano

22. pathogenesis passage of large, hard stools, which may be the initiating factor; inappropriate diet; previous anal surgery; childbirth; and laxative abuse.

23. symptoms With defecation, the ulcer is stretched, causing pain and mild bleeding.

24. types Acute fissure in ano Chronic fissure in ano

25. Acute fissure in ano Short history Painful No sentinel pile on examination Managed conservatively

26. Chronic fissure in ano Recurrent acute fissure Associated with sentinel pile Can be treated conservatively initially but may require surgery Sentinel pile : a skin tag formed due to chronic inflammation and fibrosis

27. treatment Non surgical Surgery AIM: To increase the blood supply to promote healing of the ulcer/fissure

28. Non surgical treatment Stool bulking agents Hot tub baths/ Sitz bath Local ointments Lignocaine Nitroglycerine Dietary modifications Botox injections

29. surgical Sphincterotomy Internal anal sphincter is cut to relieve the spasm and in turn increase blood supply to the fissure Midline sphincterotomies cause key hole defects, hence lateral sphincterotomy is done. 2 types : Open Closed

30. Open sphincterotomy

31. Closed sphincterotomy

32. Anal sepsis and fistulae Anorectal abcess – acute form of anal sepsis Fistula in ano – chronic form of the disease process Anal fistula : communication between an internal opening in the anal canal and an external opening through which an abscess drained.

33. etiology Infection of obstructed anal glands : Most common cause Trauma Foreign body Tuberculosis Actinomycosis Inflamatory bowel disease

34. classification

35. treATMENT

36. Anorectal abcess

37. Perianal abscess Results frtom suppuration of anal gland or suppuration of a thrombosed external pile Lies in the region of subcutaneous portion of external sphincter

38. Clinical features Severe pain in perianal region Difficulty in sitting Tender smooth and soft swellling in the perianal region

39. treatment Sitz bath Antibiotics Drainage under GA

40. Ischiorectal abcess Due to extension of intermuscular abcess through external sphincter Can be blood born as well Fat in fossa more prone for infection as it is least vascularized Both these fossa are connected  one fossa infection may lead to the infection on other side HORSE SHOE ABCESS

41. Clinical features Tender, indurated , brawny swelling in the skin over ischiorectal fossa Fever Swelling is not well localized so it is difficult to elicit fluctuation.

42. treatment Cruciate incision and drainage Pus for c/s Look for any internal opening (for presence of internal fistula)

43. Submucous abcess Occurs above the dentate line Can be drained with a sinus forceps through proctoscope

44. Fistula in ano Etiology Cryptoglandular sepsis(most common) Trauma Crohn’s disease Malignancy Radiation tuberculosis,actinoymycosis

45. Clinical features Persistent drainage from internal or external opening Indurated tract can be palpable on per rectal examination . External opening easily found but finding the internal opening can be a challenge

46. Goodsall’s rule ‘In general, fitulas with external opening anteriorly connect to internal opening by a short,radial tract. ’ Fistulas with external opening posteriorly track in curvilinear fashion to posterior midline. EXCEPTION : anterior external opening >3cm from anal verge  usually follow curved track to posterior midline

47. Classifications of fistula in ano P ark’s classification High and low fistula in ano Simple and complex fistula in ano

48. Park’s classification Intersphincteric Transsphincteric Suprasphincteric Extrasphincteric

49. Special investigations Trans rectal ultrasound (TRUS)/ Endoanal ultrasound Fistulogram MRI

50. Surgical management Fistulotomy Fistulectomy Setons

51. fistulotomy ‘Laying open of the fistula tract from its termination to source’ Applied mainly to intersphincteric and transphincteric fistula involving less than 30% of voluntary muscle. Staged sphincterotomy : part of sphincter is divided and rest tied upon by a seton .

52. fistulectomy Coring out of the fistula

53. setons Latin for Bristle Loose and tight setons : depending upon the intent of cutting through the muscle. After tying, these are tightened in intervals of weeks. ‘Cheese wire cutting through ice’ They gradually cut through the muscles without springing them apart

54. Staged fistulotomy

55. Recent advances Advancement flaps Tissue glues

56. Pilonidal sinus(jeep bottom) Pilus = hair , nidus = nest Of infective origin Occurs in sacral region between the buttocks Other sites : umbilicus, web spaces of fingers(in barbers)

57. pathology Hair penetrate skin causing dermatitis and infection Persistent infection leads to sinus formation Primary sinus : midline Secondary sinuses : paramedian

58. Clinical features Serosanguinous or purulent discharge Throbbing and persistent pain Sometimes tender swelling in the midline Tufts of hair may be seen in the opening of sinus

59. treatment Excision of the sinuses Laying open the sinus Z- plasty Rotation flaps Bescom’s operation Karydaki’s operation

60. Anal intraepithelial neoplasia Virally induced dysplasia Risk factors : anoreceptive intercourse and HIV Usually patients are asymptomatic Based on degree of dysplasia : AIN I, AIN II, and AIN III AIN II and III have chances of progressing to invasive carcinoma

61. Clinical features 30%  asymptomatic Suspicious areas are raised, scaly, white, erythematous , pigented or fissured.

62. management Multiple mapping biopsies Excision followed by colostomy or flaps Topical imiquimod or retinoids have some effect on progression of diesease .

63. Non malignant strictures Spasmodic : due to anal fissure. Organic : Postoperative Irradiation stricture Senile anal stenosis Lyphogrnuloma inguinale Inflamatory bowel disease Endometriosis

64. Clinical features Increasing difficulty in defecation ‘Pipe stem’ stools. Stricture can be palpated as annular or tubular on DRE.

65. treatment Dilatation by bougies . Anoplasty . Colostomy. Rectal excision and coloanal anastomosis .

66. Malignant tumors Below dentate line : SCC Above dentate line : basaloid , cloacogenic or transitional carcinomas.

67. Squamous cell carcinoma Risk factors : HPV infection AIN Immunosuppression

68. Clinical features Pain Bleeding Pruritus Fecal incontinence as a result of sphincter invasion. Palpable as indurated , irregular, tender ulcers.

69. management Primary treatment : chemoradiotherapy CMT(combined modality treatment) 5-FU with mitomycin C or cisplatin Resection indicated in Small marginal tumors Persistent or recurrent disease  followed by colostomy

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