BENIGN ANORECTAL DISEASES and their causes.pptx

Approach to Benign anorectal diseases

1. BENIGN ANORECTAL DISEASES

2. Introduction Benign anorectal diseases are non-cancerous conditions affecting the anorectum Several disease entities fall under this category These disease conditions often have different aetiological but may share similar symptoms A good clinical and appropriate investigative modalities are key to diagnosis Treatment may be conservative or surgical Prognosis of these conditions are generally good though recurrence may occur in some

3. Benign anorectal diseases Hemorrhoids Perianal abscess Fistula-in- ano Pruritus-in- ano Fissure-in- ano Functional rectal pain Condyloma Rectal prolapse Fecal incontinence

4. Main symptoms of anorectal diseases Bleeding per rectum Anal pain Altered bowel habit Mucus discharge Tenesmus Anal swelling Prolapse

5. Haemorrhoids Definition: Haemorrhoids or piles are symptomatic anal cushions Haemorrhoids represent dilatation or varices of the vessels of the superior and/or inferior rectal plexuses of veins The anal vascular cushions act to assist the anal sphincter in maintaining continence. There are three  vascular cushions  in the anus, positioned at the 3-, 7-, and 11- o’clock positions (when looked at with the patient in the lithotomy position, i.e. anterior is 12 o’clock) Prevalence : - Symptomatic haemorrhoids occur in over 4 % of the general population - Prevalence peak age is at 45-65yrs

6. Aetiology No concensus Certain risk factors have been identified Varicose dilatation of the internal haemorrhoidal plexus is usually regarded as the cause of internal haemorrhoids Physiological dilatation, present already in infancy, is presumed to develop into varicosities under the influence ofa wide range of factors.

7. Predisposing factors The predisposing factors include heredity, age, sex,pregnancy , ascites the puerperal state and even temperament The precipitating factors comprise cathartic abuse, diarrhoea,enemata , chronic constipation, infection, anal spasm or atony of the anal sphincter, obesity and rise in intra-abdominal pressure Attempts to expel scybalous masses from the rectal ampulla produce congestion of the internal haemorrhoidal plexus by compression of the low pressure superior haemorrhoidal veins while permitting arterial input from the superior rectal artery.

8. Surgical pathology of haemorrhoids The varicose submucosal branches of the superior and inferior haemorrhoidal veins constituting the internal and external haemorrhoidal plexuses are congregated into 3 primary positions - right anterior, right posterior and left lateral depending on the pattern of termination of the superior rectal artery These represent the anal vascular cushions which act to assist the anal sphincter in maintaining continence. These three   vascular cushions in the anus are positioned at the 3-, 7-, and 11- O’clock positions (when looked at with the patient in the lithotomy position, i.e. anterior is 12 o’clock) and represent the position of primary haemorrhoids

9. The three primary positions of haemorrhoids

10. Haemorrhoids can be : -Internal - Intero -external -External

11. Classification of haemorrhoids Haemorrhoids are  classified according to their size: Four degrees of haemorrhoids First degree – bleed only, no prolapse Second degree – prolapse, but reduce spontaneously Third degree – prolapse and have to be manually reduced Fourth degree – permanently prolapsed

12. Symptoms -Bright-red, painless bleeding per rectum -mucous discharge -Prolapse -Pain only on prolapse or complicated e.g thrombosed

13. Complications of haemorrhoids Strangulation and thrombosis Ulceration Gangrene Portal pyaemia Fibrosis Profuse haemorrhage (Rare, The cause usually lies in a bleeding diathesis or the use of anticoagulants)

14. An attack of piles. Prolapsed strangulated piles, as commonly seen, on the left. A less common mass on the right with fibrofatty covering

15. Diagnosis History and physical examination Anoscopy / Proctoscopy Colonoscopy to rule out colorectal malignancy/other differentials

16. Treatment Conservative a) -Asymptomatic haemorrhoids require no treatment but constipation and catharsis which lead to straining at stools should be avoided - Patients with constipation should be advised to take high fibre diet,at least 3 litres of fluids a day and open their bowels at a regular time - Sitz bath (Warm water Salt + antiseptic e.g Dettol or Warm water + Potassium permanganate)

17. Treatment b) Injection Sclerotherapy: This involves the injection of an irritant sclerosant solution submucosally in the areolar tissue surrounding the internal haemorrhoids The fibrosis, which follows the chemical inflammation,leads to obliteratlon of the varicose vein Suitable for first degree and early second degree haemorrhoids where only bleeding per rectum is the problem Five per cent phenol in almond or arachis oil is the most frequently used as sclerosing agent

18. Gabriel’s syringe for injection sclerotherapy,now replaced by disposable syringes

19. Treatment c) Rubber Band Ligation A rubber band is placed around the base of the haemorrhoids using a special "gun" This is a suitable means of treating first and second degree haemorrhoids in the absence of the external haemorrhoidal component or anal tags To avoid undue pain it is essential to place the bands about 0.5 to lcm above the dentate line

20. Barron’s banding apparatus, with the appearance of a typical ‘banded’ haemorrhoid

21. Treatment d) Cryosurgery Rapid freezing followed by rapid thawing destroys cellular membrane; this leads to necrosis of circumscribed areas of tissues Using liquid nitrogen, temperarures of-160°C can be readily achieved and at this level almost immediate anaesthesia is produced so that the procedure is quite painless The cryoprobe is placed on each haemorrhoid and freezing carried out for about 3 minutes. An ice ball forms as a visible white area which delineates the area which will slough eventually

22. Treatment Drugs : Flavonoid compounds (Daflon500-hesperidin in combination with diosmin ) suppress bleeding by increasing venous tone and venous return, decreasing stasis and capillary hyperpermeability

23. Surgery Open haemorrhoidectomy (Milligan & Morgan’s technique) Closed haemorrhoidectomy Staplers

24. The appearance of the anus at the conclusion of the operation. (Note that to avoid stricture formation, it is necessary to ensure that a bridge of skin and mucous membrane remains between each wound.) ‘If it looks like a clover the trouble is over, if it looks like a dahlia, it is surely a failure.’

25. Complications of haemorrhoidectomy Early -Pain -Acute retention of urine -Reactionary haemorrhage Late -Secondary haemorrhage -Anal stricture -Anal fissure - Faecal Incontinence

26. Lithotomy position for haemorrhoidectomy

27. Anorectal abscesses An anorectal abscess originates from an infection arising in the cryptoglandular epithelium lining the anal canal The internal anal sphincter is believed to serve normally as a barrier to infection passing from the gut lumen to the deep perirectal tissues This barrier can be breached through the crypts of Morgagni, which can penetrate through the internal sphincter into the intersphincteric space.

28. Types of anorectal abscesses Diagram showing the spaces in relation to the anus and types of anorectal abscess in coronal section: A, pelvirectal supralevator space; B, ischiorectal space; C, perianal or superficial ischiorectal space; D, marginal or mucocutaneous space; E, submucous space; F, anorectal intermuscular ( intersphincteric ) space; 1, pelvirectal supralevator abscess; 2, submucous abscess; 3, ischiorectal abscess; 4,marginal abscess; 5, perianal abscess; 6, intersphincteric abscess

29. Anorectal abscesses Anorectal sepsis is more common in men than women Once infection gains access to the intersphincteric space, it has easy access to the adjacent perirectal spaces Extension of the infection can involve the intersphincteric space, ischiorectal space, or even the supralevator space In some instances, the abscess remains contained within the intersphincteric space Fistula in ano is a common complication of anorectal abscesses

30. Aetiology of anorectal abscesss Sepsis unrelated to anal gland infection may occur following haemorrhoidal Sclerotherapy, infected haematoma Foreign body Trauma Underlying rectal disease, such as neoplasm and particularly Crohn’s disease Patients with generalised disorders, such as diabetes and acquired immunodeficiency syndrome (AIDS)

31. Clinical features Usually produces a painful, throbbing swelling in the anal region The patient often has swinging pyrexia Features from underlying conditions such as fistula- in- ano (most common), Crohn’s disease, diabetes, immunosuppression

32. Diagnosis Clinical features especially careful examination Proctoscopy Sigmoidoscopy Ultrasound scan Examination under anaesthesia

33. Treatment Usually surgical drainage of the abscess Perianal and ischiorectal sepsis (with an incidence of 60 and 30 per cent, respectively), drainage is through the perineal skin, usually through a cruciate incision over the most fluctuant point, with excision of the skin edges to deroof the abscess Pus is sent for microbiological culture Antibiotics Analgesia Rarely, a colostomy may be necessary to control severe sepsis, especially in the immunocompromised individual

34. Incision of an ischiorectal abscess The cavity is explored and, if septa exist, they should be broken down gently with a finger and the necrotic tissue lining the walls of the abscess removed by the finger wrapped in gauze. It is wise to biopsy the wall and send the pus for culture. Nothing further is done at this stage

35. Fistula-in- ano A fistula- in- ano , or anal fistula, is a chronic abnormal communication, usually lined to some degree by granulation tissue, which runs outwards from the anorectal lumen (the internal opening) to an external opening on the skin of the perineum or buttock (or rarely, in women, to the vagina)

36. Aetiology Congenital conditions e.g Rectal duplication Chronic inflammatory diseases e.g Crohn’s disease,ulcerative colitis, tuberculosis, lymphogranuloma venereum , actinomycosis , Foreign body Malignancy (which may also very rarely arise within a longstanding fistula), and suspicion of this should be aroused if clinical findings are unusual However,majority are termed non-specific, idiopathic or cryptoglandular Intersphincteric anal gland infection is deemed central to them.

37. Clinical features of fistula-in- ano Non-specific anal fistulae are more common in men than women The overall incidence is about nine cases per 100000 population per year in Western Europe Patients in their third, fourth and fifth decades of life are most commonly affected Patients usually complain of intermittent purulent discharge (which may be bloody) and pain (which increases until temporary relief occurs when the pus discharges) There is often, but not invariably, a previous episode of acute anorectal sepsis that settled (incompletely) spontaneously or with antibiotics, or which was surgically drained The passage of flatus or faeces through the external opening is suggestive of a rectal rather than an anal internal opening

38. Classification of fistula-in- ano The most widespread and useful classification of anal fistulae is that proposed by Parks, based on the centrality of intersphincteric anal gland sepsis (the internal opening is usually at the dentate line), which results in a primary track whose relation to the external sphincter defines the type of fistula and which influences management Could be classified as “Low” or “High” ;”Simple” or “Complex” fistula in ano,depending on the nature of the tract and complexity therefore in terms of pathology and management

39. Fistulae are classified according to their position relative to the anorectal ring . They are divided into two groups (1) Low level (2) High level. Low level variety: The internal opening lies below the anorectal ring. Three types may be identified: ( i ) Subcutaneous (ii) Submucous (iii) Intermuscular (Low Anal) High level variety : These are uncommon and are commonly iatrogenic or secondary to colo -rectal or pelvic conditions. The internal opening passes through or lies above the anorectal ring. The following types are seen: ( i ) Pelvi -rectal ( supralevator ) (ii) High intersphincteric (iii) High subrnucous

40. Fistula-in- ano according to Park can also be classified as: i ) Intersphincteric (most common,45%)- the tract is confined to this space i.e does not cross the external sphincter ii) Trans- sphincteric (40%)- the tract connects the intersphincteric tract to the ischlorectal fossa by passing through the external sphincter, iii) Suprasphincteric - the tract loops over the external sphincter and perforates the Ievator , iv) Extrasphincteric - the tract passes from the rectum to the peri-anal skin external to the sphincter complex

41. Types of anal fistula (Parks’ classification): 1, intersphincteric ; 2, trans- sphincteric ; 3, suprasphincteric ; and 4, extrasphincteric primary tracks

42. Assessment of patients with fistula-in- ano A full medical (including obstetric, gastrointestinal, anal surgical and continence) history and proctosigmoidoscopy are necessary to gain information about sphincter strength and to exclude associated conditions The key points to determine are the site of the internal opening; the site of the external opening(s); the course of the primary track; the presence of secondary extensions;and the presence of other conditions complicating the fistula. margin suggests a relatively superficial track, whereas supralevator Palpable induration between external opening and anal induration suggests a primary track above the levators or high in the roof of the ischiorectal fossa, or a high secondary extension Intersphincteric fistulae usually have an external opening close to the anal verge

43. Salmon- Goodsall’s Law If a transverse line were drawn across the midpoint of the anus, fistulae with their external openings behind the transverse line tend to take a curved course terminating in an opening in the midline of the posterior wall of the anal canal whilst those with their external openings anterior to this line usually run directly in a straight line with the internal opening usually in a crypt immediateIy opposite The exception to this rule occurs in a long anterior fistula if an anterior external opening is greater than 3 cm from the anal margin. The internal opening is then more likely to be in the midline posteriorly

44. Goodsall’s law (rule)

45. Investigations Fistulogram MRI is the investigation of choice Investigations to rule out potential aetiology e.g Chest –ray to rule out Tuberculosis etc Swab of fistula discharge for microscopy,culture and sensitivity Histology of curreted tissue obtained at surgery

46. Treatment Conservative with antibiotics and sit bath Use of setons Surgery : -Fistulotomy - Fistulectomy - Plastic procedures using flaps - Defunctioning colostomy sometimes done to encourage healing of the fistula Recurrence rate is high irrespective of method of treatment. Its best treated by a Proctologist

47. Fissure-in- ano Definition An anal fissure ( fissure- in- ano ) is 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

48. Aetiology Not well understood Classically, acute anal fissures arise from the trauma caused by the strained evacuation of a hard stool or, less commonly, from the repeated passage of diarrhea Anterior anal fissure is much more common in women and may arise following vaginal delivery - Perpetuation and chronicity may result from repeated trauma, anal hypertonicity and vascular insufficiency, eithersecondary to increased sphincter tone or because the posterior commissure is less well perfused than the remainder of the anal circumference.

49. Clinical features Commoner in young adults though affects all ages from infancy to the elderly Male to female ratio is the same Acute anal fissures are characterized by severe anal pain associated with defaecation ,often recurrent Passage of fresh blood, normally noticed on the tissue after wiping,mucous discharge or constipation Chronic fissures are characterised by a hypertrophied anal papilla internally and a sentinel tag externally (both consequent upon attempts at healing and breakdown), between which lies the slightly indurated anal ulcer overlying the fibres of the internal sphincter Itching due to irritation from sentinel tag,discharge from associated ulcer/fistula in ano

50. Clinical features Anal fissure Acute or chronic Ischaemic ulcer in the midline of the anal canal Ectopic/atypical site suggests a more sinister cause e.gCrohn’s disease, tuberculosis, sexually transmitted or human immunodeficiency virus (HIV)-related ulcers (syphilis, Chlamydia , chancroid, lymphogranuloma venereum , HSV, cytomegalovirus, Kaposi’s sarcoma .Biopsy of the fissure should be taken in such cases

51. Treatment Conservative stool softeners Sitz bath High fibre diet The mainstay of current conservative management is the topical application of pharmacological agents that relax the internal sphincter, most commonly nitric oxide donors ( Scholefield ) By reducing anal sphincteric spasm, pain is relieved, and increased vascular perfusion promotes healing. Such agents include glyceryl trinitrate (GTN) 0.2 per cent applied four times per day to the anal margin (although this may cause headaches) and diltiazem 2 per cent applied twice daily.

52. Treatment Anal dilatation Fissurectomy with lateral internal anal sphincterotomy Advancement flaps A dreaded complication of the lateral sphinterotomy is anal incontinence

53. Pruritus Ani This is intractable itching around the anus, a common and embarrassing condition. Usually, the skin is reddened and hyperkeratotic and it may become cracked and moist Common Numerous causes including poor anal hygiene, skin diseases, parasites (threadworm), anal discharge, vaginal discharge, especially caused by Trichomonas vaginalis infection, allergies, diabetes,psychoneurosis etc Treat the cause if possible Symptomatic treatment is the mainstay and good anal hygiene