Anal Canal

Property of Prof Dr. Nawel Matar FRCS, Department of General Surgery, Faculty of Medicine. University of Zagazig

1. بسم الله الرحمن الرحيم

2. Anal canal PROF. DR. NAWEL MATAR FRCS (Ed., UK)

3. Anal canal Anatomy of the anal canal: Length : 4 cm in adults. It passes downwards and backwards. Its anterior wall is shorter than the posterior wall. Divisions : Upper 2/3 derived from the endoderm. Lower 1/3 derived from ectoderm. This account for the division of: Mucous membrane lining. Blood supply. Lymphatic drainage.

4. Anal canal The mucous membrane: Above the pectinate line (upper 2/3 third): epithelium is similar to the rectal mucosa (columnar epith .) Between the pectinate line and the white line of Helton: a zone of transitional epithelium. Below the white line: stratified squamous epith . (Skin & its appendages). Blood supply: Above the pectinate line: Superior rectal artery. Below the pectinate line: Inferior rectal artery. Venous drainage : Above the pectinate line: external rectal plexus to the middle and the superior rectal veins. Below the pectinate line: to inferior rectal veins.

5. Anal canal

6. Anal canal Lymphatic drainage: Accompany the arteries, Above the pectinate line: para -rectal LN to the inferior mesenteric LN. Below the dentate line: to superficial and deep inguinal LN. Nerve supply: Above the pectinate line : Autonomic N. supply ,via superior and inferior hypogastric ganglia(not sensitive ) Below the pectinate line : somatic N. supply , via inferior branch of the pudendal nerve ( S2&S3 ) and the perineal branch of S4 ( sensitive )

7. Anatomy of the rectum Length: 18 – 20 cm. The recto- sigmoid junction lies opposite to the sacral promontory. A/P curve follows the curve of the rectum. Three lateral curves form three horizontal folds called valves of Houston.

8. Anatomy of the rectum Divisions: Upper 1/3 is covered by the peritoneum from the front and the sides. Middle 1/3 (the widest part) is covered by peritoneum from the front only. Lower 1/3 : no peritoneal covering , it lies within the muscles of pelvic floor and separated by fascial condensations : Denonvillier fascia: from the prostate, in front and behind. Waldeyer's fascia: from the coccyx and the last 2 sacral vertebrae. These fascial layers are of surgical importance as they are barriers against malignant penetration and also of great value as a guide during operations. Mucous membrane: Columnar epithelium with scattered goblet cells.

9. Anatomy of the rectum Arterial supply: Superior rectal artey : branch of the inferior mesenteric artery. Middle rectal artery: branch of internal iliac artery. Inferior rectal artery: branch of the pudendal artery. Venous drainage: Internal rectal plexus lies in the submucosa , draining to the superior rectal v. which is a tributary of the inferior mesenteric v. (portal circulation). External rectal plexus: lies outside the external muscle coat, drain to the middle rectal v., a branch of the internal iliac v. (systemic circulation).

10. Anatomy of the rectum Lymphatic drainage : Accompanies the arteries. Upper 1/2: drains with the superior rectal artery to the rectal LN of Gerata , to the inferior mesenteric group. Lower 1/2: with the middle rectal artery, to the internal iliac LN. Nerve supply: Autonomic via the superior (sympathetic) and the inferior (parasympathetic) hypogastric plexus.

11. Anatomy of the rectum

12. HAEMORRHOIDS (PILES) Definition : Enlarged , congested or prolapsed patches of the mucosa and submucosa (anal cushions) at the level of anorectal junction . Definition : Haemorrhoids are varicosities of tributaries of superior rectal vein (internal piles) or external plexus of veins (external piles). Aetiology : Primary (Idiopathic) : No known cause: Predisposing factors: Hereditary ( congenital ) Prolonged straining as with : Chronic constipation. Childbirth : straining during labour . Senile enlarged prostate. Relaxation of anal sphincter : old age

13. HAEMORRHOIDS (PILES) Aetiology : Secondary : due to obstruction to the flow of blood from the superior rectal vein. Cancer rectum. Compression by pregnant uterus. Compression by pelvic tumour . Portal hypertension. Cardiac failure

14. HAEMORRHOIDS (PILES) Pathology: Site: with the patient lies in the lithotomy position, the usual arrangement according to the branches of superior rectal vessels which form a sort of vascular plexus under the epithelial lining of the anal canal. There is three main piles occur at 3,7,11 o’clock position with daughter piles in between. Composition: each pile mass consists of a central artery and a punch of veins surrounding it, held together by areolar tissue

15. HAEMORRHOIDS (PILES)

16. HAEMORRHOIDS (PILES)

17. HAEMORRHOIDS (PILES) Classification: External haemorrhoids : located below the dentate line, which may be : Acute: acute perianal haematoma due to rupture of dilated vein around the anus. Chronic : skin tags at the base of anal fissure (sentinel pile) Skin tags following thrombosed external pile Internal Haemorrhoids : congested vascular cushion located above the dentate line.

18. HAEMORRHOIDS (PILES) Complications: Anaemia : follow continued bleeding. Partial Rectal Prolapse : due to long standing pile. Thrombosis and strangulation: occurs when prolapsed piles gripped by anal sphincter. After 2 or 3 weeks the prolapsed pile become fibrosed with self cure. In severe strangulation ,gangrene may occurs. Infection: peri -anal abscess, portal pyaemia (rare) may complicate infected piles.

19. HAEMORRHOIDS (PILES) Clinical Features: AGE: piles occur at all ages, but uncommon below the age of 20 years. Symptoms: Rectal Bleeding: It is the most common presentation of haemorrhoids Painless, bright red occurs during defecation usually at the end. If is small quantity, it may just streaks of blood over the feces. If it is copious, it may jet or drip into the lavatory pan (separate from the stool). Pile Prolapse : The patient notices a lump felt after defecation. It may return to the rectum spontaneously or need to be pushed back.

20. HAEMORRHOIDS (PILES) Pruritis (itching): Exposed rectal mucosa causes peri -anal irritation and mucous staining on the underwear. Pain: Haemorrhoids are usually painless, unless complicated by thrombosis . Grading of haemorrhoids . First degree : piles bleed but don’t prolapse Second degree: piles prolapse on defecation, but reduced spontaneously. Third degree : piles prolapse during defecation but must be reduced manually Fourth degree: piles remains persistently prolapsed.

21. HAEMORRHOIDS (PILES)

22. HAEMORRHOIDS (PILES) Examination: Abdomen: to exclude causes of secondary haemorrhoids , e.g. pelvic tumours , cirrhotic liver. Rectum Inspection – look for: external haemorrhoids Associated anal fissure or fistula prolapse through the anus with strain (first and second degree piles are not seen , can only be diagnosed with protoscope ) palpation (PR) : piles can not be felt with the finger. P.R. is essential to exclude: palpable cancer rectum, anal stenosis , prostatic hypertrophy. protoscopy : to visualize internal haemorrhoids . The pile is seen as purple bulging into the proctoscope at 3,7,11 o’clock position when the patient lies in the lithotomy position. Sigmoidscopy : should be performed routinely to exclude rectal carcinoma. Colonoscopy: in all patients over 50 years old, a complete colonoscopy should be performed.

23. HAEMORRHOIDS (PILES) Treatment: Before start treatment, you should exclude cancer rectum first and other causes of secondary haemorrhoids . Treatment of secondary piles is the treatment of the cause. Conservative Treatment : Indications: ideal for first, second and early third degree hemorrhoids Method: Avoid straining at defecation Bulk forming diet (rich in fruits, vegetables and bran) is advised. Increase the water intake Bulk laxative Pruritis is treated by improve hygiene not by topical medications which is ineffective.

24. HAEMORRHOIDS (PILES) Injection sclerotherapy : Indications: Small first and second degree haemorrhoids Daughter piles remaining after surgery Recurrent piles Bleeding secondary piles Method: Performed in the office through an anoscope (painless). 1 to 3 ml of sclerosant (5% phenol in almond oil) are injected in the submucosal space not in the vessels of each haemorrhoids ( extravascular ). Idea: it induce fibrosis which constricts the blood vessels and fixes the mucosa to the muscles. Complications: ulceration – infection – stricture from excessive fibrosis.-Pain if injection is done low in the sensitive area of the anal canal.

25. HAEMORRHOIDS (PILES)

26. HAEMORRHOIDS (PILES) Rubber Band Ligation : Indications : suitable for first, second and early third degree haemorrhoids Method : performed in the office through an anoscope Tight rubber band is placed on the rectal mucosa just above the internal haemorrhoids using rubber band ligator Idea: the strangulated mucosa falls away after few days. Complications: it is painless, but: Immediate severe pain which is an indication of misplaced band. Delayed anal pain, fever and urinary retention is a due to peri -anal infection.

27. HAEMORRHOIDS (PILES)

28. HAEMORRHOIDS (PILES) Infra-red Photocoagulation : Indications: indicated for first and second degree piles. Method: infra red probe is applied just above each pile through an anoscope . Cryo - Surgery : Indications : first and second degree piles Idea: rapid cooling followed by rapid thawing will cause the pile to slough. Complications: Watery discharge follow the operation which may persist for weeks. Stricture may follow excessive fibrosis.

29. HAEMORRHOIDS (PILES) Surgery : Haemorrhoidectomy Indications: Third and fourth degree piles Mixed internal and external piles Associated pathology as ulceration, fistula, fissure, skin tags Idea: based on excising hypertrophied vascular cushions with the redundant mucosa and skin over it.

30. HAEMORRHOIDS (PILES) Method: Open method – (Milligan and Morgan) Resection of haemorrhoidal tissues, allow it to heal by secondary intension. Closed method: Resection of haemorrhoidal tissues and closure of the wound with absorbable sutures.

31. HAEMORRHOIDS (PILES)

32. HAEMORRHOIDS (PILES) Complications of surgery: Acute Retention of Urine : (common) due to anal pain post operatively Treatment: Analgesic Hot fomentation to supra-pubic region Catheterization

33. HAEMORRHOIDS (PILES) Haemorrhage : Reactionary: On the night of the operation (first 24 h.). Treatment: Bleeding point is ligated or coagulated by diathermy. Anal pack Secondary : from 7 th to 10 th day after surgery. Treatment : Blood transfusion Morphia Antibiotics Anal pack with gauze around a wide bored rubber tube, removed after 40 hrs.

34. HAEMORRHOIDS (PILES) Stricture : Cause: Excessive amount of skin and mucosa are excised Infection post operatively Treatment Anoplasty Recurrence : daughter piles not excised Anal fissure : due to failure of the wound to heal. Peri -anal Infection : abscess or fistula

35. HAEMORRHOIDS (PILES) Management of Special Cases: Thrombosed Strangulated Pile : Conservative – Analgesic to relieve pain Bulk forming diet Warm sitz baths Haemorrhoidectomy : urgently for strangulated pile. Acute Haemorrhoidal Bleeding in Portal Hypertension : Avoid haemorrhoidectomy because of the risk of massive, uncontrollable bleeding. Suture ligation of the bleeding site incorporating mucosa, submucosa and internal sphincter. Correct any co-existing coagulopathy Lower the portal venous pressure.  Acute perianal hematoma: Acute perianal hematoma occurs due to rupture of a dilated anal vein due to straining. A painful, tense, tender and bluish swelling around the anal verge (usually laterally) It usually resolves spontaneously with time. So treatment is mainly conservative. However, if the pain is severe or if infection occurs, hematoma should be evacuated surgically.

36. ANAL FISSURE Definition: It is a longitudinal tear (or ulcer) in the skin lining the anal canal distal to the dentate line. Aetiology : Trauma: Passage of large hard stool Prolonged diarrhea Excessive straining e.g. during child birth, anterior fissure may occur due to over stretching of the wall of anal canal Iatrogenic injury : by enema nozzle or endoscope Rarely, Crohn’s disease

37. ANAL FISSURE Pathology: Site : Midline: Posterior: 90%, more common in males Anterior: (10-15%) commoner in females due to weakened perineal floor following tears at child birth. Lateral: (< 1%) may indicate underlying disease such as Crohn’s disease.

38. ANAL FISSURE Types: Acute: Superficial tear in the lower half of the anal canal causes spasm of the internal sphincter, this spasm results in pain which in tern increases spasm and a vicious circle occurs .The spasm increases tearing and decreases blood supply. This cycle of pain, spasm, ischaemia , prevents healing. Chronic: Occurs if the fissure is not treated properly, characterized by: Ulcer : fibrotic base Sentinel pile : oedematous skin tag on anal verge Hypertrophied anal papillae at the upper end of the fissure. Complications: Infection – leads to peri –anal abscess and fistula formation.

39. ANAL FISSURE Clinical Features: Anal Fissure is an extremely common condition Age: between 20 and 40 years old Sex: frequently common in women after childbirth Symptoms: Pain : tearing pain with defecation painful anal spasm lasting for several hours after defecation Bleeding : blood with streak the stool Constipation : the patient becomes frightened to defecate, because of pain Reflex symptoms: retention of urine. dysparunia

40. ANAL FISSURE Examination: Inspection The two gluteal folds are gently separated; the fissure is seen as a posterior tear of the anal verge. Chronic fissure is seen with the sentinel pile protruding from the anus Palpation: Acute fissure – it is impossible to do P.R examination, as the patient can’t tolerate digital examination. Chronic fissure: The fissure is felt as small fibrotic defect ( indurated edges ) Streak of blood is detected on the examining finger.

41. ANAL FISSURE Treatment: A) Acute fissure: Conservative : Avoid constipation – by bulk forming diet, lubricant laxative and proper anal hygiene Topical anaesthetic jelly – is applied on the fissure (2% lidocaine ) before bowel movement. Warm sitz baths (relax anal canal) after defecation. N.B Recently; Nitroglycerine (0.2%) ointment is applied twice a day to relax the sphincter and improve the blood flow but it causes severe headache. It allow fissure healing after 6 weeks in 50% of cases. Botulinum Toxin A – injection into the sphincter causes temporary muscle paralysis and may enhance fissure healing. Incontinence is rare. Surgical : Lateral Internal Sphincterotomy – is the procedure of choice if conservative measures fails , by using either open or closed technique, healing is achieved in more than 95% of cases.

42. ANAL FISSURE B) Chronic fissure: Treatment mainly is surgical, by: Lateral internal sphincterotomy . Fissurectomy with posterior sphincterotomy .

43. ANAL FISSURE

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