benigh perianal conditionsssssssss CI.pptx

benigh perianal conditions

1. Benign perianal conditions For CI, By Dr. Diribe Bedasa

2. Contents Anatomy Diagnosis Hemorrhoids Fissure in Ano Anorectal abscesses Fistula in Ano Rectal prolapse Refferances

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4. muscles of anal canal: -External sphincter - Puborectalis muscle -Internal sphincter -Longitudinal Muscle External spincter -Subdivided into subcutaneous superficial and deep -Attached anteriorly to perineal muscle and posteriorly to coccyx -voluntary muscle (skeletal muscle) and innervated by pudendal nerve 4

5. Anal cushion: - Uneven mucosal and submucosal folds above dentate line -Painless , it has 3 common position (Left Lateral , Right Anterior , and Right Posterior) -Submucosa lies btw epithelial layer and internal Sphincter -Contain vascular , muscular and connective tissue 5

6. BLOOD SUPPLY Supplied by superior, middle and inferior rectal arteries VENOUS DRAINAGE Upper ½ of anal canal : Superior rectal veins  tributaries of the inferior mesenteric vein Portomesenteric venous system Middle rectal veins internal iliac veins Lower ½ of the anal canal: Inferior rectal veins + Subcutaneous perianal plexus of veins eventually join the internal iliac vein on each side 6

7. Perianal spaces

8. Hemorrhoids Cushions of sub mucosal tissue containing venules , arterioles, and smooth muscle fiber. They are thought to play a role in maintaining continence. They are located in the left lateral , right anterior and right posterior. This normal tissue protects the sphincter during defecation and permits complete closure of the anus during rest. . 10

9. Pathophysiology Haemorrhoids result from sliding down ward of anal cushions. Disintegration of anchoring and supporting connective tissue. Allows the cushions to slide down Low fiber diet Small caliber stool  Straining during defecation  Causes increased pressure  Interferes with venous return  Engorges the haemorrhoids Prolonged sitting on a toilet (e.g. while reading) May affect venous return (Tourniquet effect) Aging: weakening of support structures Facilitates prolapse of cushions

10. Risk factors Age: prevalence increases with age, Peak 46-65 years of age Sex : - equal in both sexes Diet- high fiber diet reduces prevalence Genetics- Positive family history common Socio economic - Common in higher social economic groups Constipation- Often reported by patients IBD (UC and Crohn’s disease) - Have increased risk Pregnancy- Hormonal changes

11. Types of hemorrhoids 1.internal; above dentate line 2.external; below dentate line 3.mixed; both internal and external grading Grade I Grade II Grade III Grade IV

12. 11 o’clock 7 o’clock 3 o’clock 15

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14. Earliest symptom { A splash in the pan } ( If complication ) 18

15. Complications of hemorrhoids Portal pyaemia Suppuration Fibrosis Ulceration Gangrene Thrombosis Strangulation Gripped by Ext. sphincter Impeded venous return prolapse 19

16. Thrombosed External hemorrhoids 20

17. Diagnosis Clinical history Physical Examination ( PR ) visualize with anoscope

18. 22 Treatment

19. Indications of surgery Mainly driven by impact of symptoms on quality of life 3 rd and 4 th degree piles 2 nd degree not cured by conservative means Fibrosed hemorrhoid Interno -external hemorrhoid Bleeding sufficient to cause anemia Soiling Ulceration, thrombosis, gangrene 23

20. Post OP care Sitz bath Analgesics Antibiotics Laxative Dressing P/R after 3 weeks

21. Infected cavity filled with pus found near the anus or rectum Anorectal abscess

22. Anorectal Suppuration Epidemiology Anorectal abscesses (“Acute phase”) 100,000 cases per year Age range 20-60, 2:1 ratio M:F 30% recurrence rate Anorectal fistula (“Chronic phase”) 25-40% of abscesses lead to fistula 10-20% recurrence rate 26

23. Abscess - Etiology Nonspecific crypto glandular (90%) Specific causes: Specific infection, ie TB, actinomycosis , lymphogranuloma venereum , Inflammatory bowel disease, Trauma or foreign body Surgery (episiotomy, hemorrhoidectomy , prostatectomy), Malignancy - carcinoma, lymphoma, radiation-related

24. Classification of Anorectal Abscesses 28

25. Supralevator Space Intersphincteric Space Ischioanal Space Horseshoe abscess 29

26. Clinical Presentation s Pain Severe, constant pain, worse with movement/pressure (sneezing, coughing, bearing down),better with drainage Swelling, Fever chills hallmark symptoms supralevator abscess may have gluteal pain rectal pain with urinary symptoms ( ie . Constipation, Urinary retention) - possibly indicate intersphincteric or supralevator abscess Anorectal Absces 30

27. Anorectal Abscess Clinical Presentation Exam Induration , fluctuance , erythema , warmth, purulent drainage DRE 31

28. Abscess … Treatment Exam under anesthesia for pain out of proportion to exam Incision and drainage - trim edges to prevent coaptation I&D of supralevator abscess: depends on location - intersphincteric origin then divide internal sphincter and drain into rectum; if arises from ischianal abscess can be drained through perineal skin - sitz bath -Antibiotics? 32

29. Abscess - Complications Recurrence -recurrence in as many as 89% of pts -Extra-anal causes -should be evaluated for recurrent disease ( hidradenitis suppurativa , Crohn’s) Incontinence iatrogenic (superficial external sphincter), inappropriate wound care (excessive scarring from prolonged packing) 33

30. Abscess Complications.. Necrotizing anorectal infection (rare) -Resuscitation, -IV abx , -wide debridement to healthy tissue 34

31. Fistula inano A track lined by granulation tissue that connects the anal canal or rectum to skin around the anus Causes Anorectal abscess which bursts spontaneously or was opened inadequately Granulomatous lesions : Tb, Crohn’s dis ., actinomycosis (multiple external openings) Carcinoma Chronic fistula may be complicated by colloid carcinoma

32. Types Low level :internal opening below the anorectal ring High level : internal opening above the anorectal ring

33. Diagnosis Persistent purulent drainage Palpable indurated tract & external openings Internal opening detected by palpation or proctoscopy Goodsall’a rule as a guide to locate the internal opening Probing Injections of methylene blue/hydrogen peroxide

34. Investigation Fistulography Exam under anesthesia (EUA) - anoscopy , proctoscopy ; assess for internal opening and occult abscess Endoluminal ultrasound MRI-most sensitive CXR (pulmonary Tb)

35. 39

36. Intersphincteric fistula 40

37. Transsphincteric fistula 41

38. Suprasphincteric fistula 42

39. Extrasphincteric fistula 43

40. 44

41. Fistula-in- ano : Treatment Eliminate fistula, Prevent recurrence, Preserve sphincter function 45

42. Fistula- In – Ano ( cont …) Surgical Treatment 1. Fistulotomy / Fistulectomy for fistula in- ano 2. Seton placement for high fistula in- Ano A. cutting seton B. Loose seton 3. Advancement flap 4. Fistulotomy and sphincter repair 46

43. Rectal prolapse Introduction Described as early as 1500 B.C 3 entities combined together 1. Full thickness rectal prolapse 2. Mucosal prolapse 3. Internal prolapse (intussusceptions) Mucosal or full thickness Their treatment differs.

44. Rectal prolapse( Cont …) Frequency It is uncommon True incidence is unknown Under reported in elderly Peak occurance In 4th and 7th decade Most (80-90%) are women Etiology Unknown But has associated abnormalities 50%of cases associated with constipation and chronic straining

45. Rectal prolapse( Cont …) Certain anatomic features are common Deep anterior Dougla’s pouch Weak pelvic floor Decreased anal sphincter tone Poor posterior rectal fixation Long rectal mesentry Redundant recto sigmoid

46. Rectal prolapse( Cont …) Pathophysiology Not completely understood 2 theories 1st theory : it is a sliding hernia through a pelvic floor defect 2nd theory : Holds that prolapse starts as circumferential internal intussusception Progresses as full thickness prolapse through time and straining. Mucosal prolapse Different etiology and pathophysiology Connective tissue attachments are weak and stretched Often continuation of haemorrhoidal disease

47. Rectal prolapse( Cont …) Mortality/ Morbidity Incarceration/ strangulation Rare, if untreated Minor rectal bleeding Anemia Ulceration, incontinence Sex Adults Male to Female: 1:6 Age All ages Peak: 4th and 7th decades Children: mainly less than 3year Peak: first year of life

48. Clinical presentation History Constipation Fecal incontinence Mucus drainage Protruding anal mass 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 Rectal prolapse( Cont …)

49. Rectal prolapse( Cont …) Causes Conditions with increased intra-abdominal pressures Constipation Diarrhea BPH COPD Pelvic floor dysfunction Anatomic features Neurologic disorders Lumbo sacral trauma Spinal tumors

50. Rectal prolapse( Cont …) Differential diagnoses Hemorrhoids Rectal polyps Intussusception (pediatrics) Work up Lab studies Based on patients age and comorbidities

51. Rectal prolapse Hemorrhoid

52. Rectal prolapse( Cont …) Imaging studies Barium enema Exclude other colonic lesions Video defecography To document internal prolapse To distinguish rectal prolapse from mucosal prolapse Other tests Colonic transit study In patients with constipation and prolapse Anal sphincter manometry Pudendal n-n terminal motor latency Assess neurologic dysfunctions

53. Rectal prolapse( Cont …) Procedures Proctosigmoidoscopy Look for ulceration (10-25%of patients) Inflammation Other colonic problems NB: The diagnosis is usually made based on history and physical examination

54. Rectal prolapse( Cont …) Treatment 1. 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 2. Surgical treatment

55. 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 ANAL FISSURE

56. 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)

57. 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

58. Fissure-In- Ano ( cont …) Treatment Medical therapy Chemical sphincterotomy Surgical treatment

59. History Age Hemorrhoids- common all ages but are uncommon below the age of 20 years. Perianal haematomata - occurs at all ages Fissure-in- ano -(acute) quite common in children Anorectal abscess- common between the ages of 20 and 50 years. Sex Hemorrhoids- common in both sexs Fissure-in- ano - common in men Anorectal abscess- more common in men Prolapse of rectum- more common in women

60. Principal symptoms of rectal and anal conditions: Bleeding Pain Change in the stool Discharge pruritis

61. Can be fresh or altered Example of altered is melaena Black tarry stool Recognizable blood may appear in four ways: Mixed with feces On the surface of the feces Separate from the feces: after/unrelated to defecation On the toilet paper after cleaning

62. History - Bleeding Diagnosis of anal conditions which present with rectal bleeding Bleeding 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 .

63. History – Anal pain Diagnosis of anal conditions which present with pain Pain 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

64. Inspection -Any skin lesions ( e.g:psoriasis,lichen planus ) Genital exm:warts,candidiasis - Anal tags,sentinel piles,fistula in ano , pilonidal sinus, and carcinoma can be diagnosed -Lubricated index finger Palpate perianal region ( e.g:induration,tenderness ) Within the lumen :tone ,length In the wall Outside the wall ( anterior, right lateral , left lateral and posterior) -Bimanual examination -Abdominal examination -Lymph nodes On withdrawal: stool colour,mucus,blood or pus