FISSURE AND HEMORRHOID.pptx............................................

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1. ANAL CANAL

2. ANATOMY OF ANAL CANAL It is 3.5-4 cm long and extends from Levator ani to anal verge The anus appears as an anteroposterior cutaneous slit like opening with its distal most part referred to as anal verge The proximal anal canal is lined by columnar epithelium and the distal part lined by squamous Junction of the above two appears as an undulating demaracation called Dentate line which represent former site of embryonic anal canal

3. The mucosa above the dentate line supplied by autonomic nerves and below by the pudendal nerve. The mucosa above dentate line appears as pleated with longutidinal folds called Columns of Morgagni There are 6-12 anal glands that secrete lubricating fluid to assist defecation which open at the base of most columns

4. The submucosa in the are of distal anal canal formed by a discontinous layer of thickened tissue creating a hemorrhoidal cushions These typically found in the Rt anterior Rt posterior and left lateral These cushions receive their blood supply from six hemorrhoidal arteries along circumference of distal rectum and anus The venous drainage is by superior, middle,inferior hemorrhoidal vessels , allowing for communication between portal and systemic circulations.

5. FISSURE IN ANO

6. Definition An anal fissure is a longitudinal ulcer in the anoderm of distal anal canal, which extends from the anal verge proximally towards , butnot beyond the dentate line.

7. Etiology Posterior midline is most commonly affected, may be due to shearing forces during defecation combined with a less elastic anoderm with an increased density of longitudinal muscle extensions in that region. More common in younger age group and in women, may arise following vaginal delivery. Internal sphincter hypertonia increases the effect of hard stool and perpetuates relative tissue ischemia with a decrease in blood supply to anal mucosa. After initial tear, vicious cycle of non healing and repeated trauma leads to development of chronic deep fissures.

8. Clinical features Most common complaint is severe anal pain, which usually resolves only to recur at the next evacuation. Bleeding per rectum, characteristically described as streaking of stool with blood. Constipation and hard stools are usually the predisposing factors of which the patient complains. In chronic fissure, patient may also complain mass per rectum which is a skin tag or sentinel pile. Multiple fissures are seen in crohn’s disease, homosexual practices and STDs

9. Treatment Conservative management : Lifestyle changes, high fiber diet, adequate water intake Laxatives Topical sphincter relaxants – Glyceryl trinitrate (NO donor), Diltiazem(calcium channel blocker) Botulinum toxin injection into internal sphincter

10. Operative measures : Lord’s anal dilatation Lateral anal sphincterotomy – internal sphincter is divided Fissurectomy and anal advancement flap

11. Lateral anal sphincterotomy steps

12. HEMORRHOIDS

13. Hemorrhoids Hemorrhoids are symptomatic enlargements of vascular cushions Derived from Greek word Haima +Rhoos means bleeding Some call them as a Pile(Latin = a ball)

14. Prevalance 4.4% in the world mostly seen in age group of 25-65 years Equal in both the genders

15. Etio-Pathogenesis Heriditary Morphological - due to weight of blood column without valves causes high pressure Straining, diarrhoea , constipation, low fiber diet ,over purgation Pregnancy, upright posture Portal HTN(Rare cause) Disruption of suspensory tissues that hold venous plexues(sliding theory) Idiopathic

16. Clinical features Bleeding - 1 st symptom- ‘ SPLASH IN THE PAN’- bright red and fresh -occurs during defecation which is often painless mass per rectum A mucoid discharge pruritis Pain- may be due to prolapse/infection / spasm Anemia(secondary )

17. Classification Based on location Primary rt ant rt post and left lateral Secondary - other than primary

18. Complications Profuse bleeding Strangulation- due to gripping in between anal sphincter Thrombosis Ulceration Gangrene Suppuration Portal pyaemia

19. Management Investigations Proctoscopic examination is the Inv of choice Points to noted on proctoscopy The number, degree and size. The surface and their apperance. Features of chronicity of hemorrhoids. Colonoscopy in elderly or in any if malignancy is suspected

20. Differentials For bleeding per anum Hemorrhoid Fissure-in-ano Polyps UC/AC Carcinoma rectum/ colon Intususseption Vascular anomalies of colorectum

21. For mass per rectum Rectal prolapse Rectal varices Adenomas Hypertrophied anal papillae Skin tags Perineal warts Carcinoma

22. Treatment Medical Sitz baths-reduces edema, pain and promotes healing Dietary modifications Laxatives Adequate toilet training

23. Dietary modifications such as atleast 35 gm/day fiber diet, plenty of water Fiber alternatives such as bulk forming agents isphagula husk, methyl cellulose etc. Squating position Laxatives to relieve constipation

24. Parasurgical Sclerotherapy Rubberband ligation Cryotherapy Infra red coagulation Laser therapy DGHAL

25. SURGICAL - gold standard for hemorrhoids Open hemorrhoidectomy Closed hemorrhoidectomy Stappled hemorroidopexy

26. Open hemorrhoidectomy - Milligan morgan technique Under SA with patient in Lithotomy , initially sphincter should be dilated to reduce the post op pain Skin is held with ALLIS and internal pile mass is held with artery Skin is cut in a “V” shaped manner and internal sphincter is seperated and pushed up Pedicle transfixed , ligated and distal part is cut.

27. The appearance post operatively shoud look like a Clover leaf rather than a Dahlia Postop patient is given antibiotics laxatives, sitzbaths and analgesics are given

28. Closed hemorrhoidectomy - Ferguson technique Procedure is similar to that of open method but the raw area is closed

29. Stappled hemorroidopexy It is circumferential excision of the mucosa and submucosa 4 cm above the dentate line using a circular stapler It is a MIPH -minimally invasive procedure for hemorrhoid Done mostly for prolapsed pile Advantages less painfull , less hospital stay with a faster recovery The excised Doughnut should be sent for HPE and the proper Doughnut SHOULDNOT contain muscler layer

30. Post operative complications Pain -due to spasm,nerve irritation, muscle injury Urinary retention seen in 50-70% cases Reactionary / secondary hemorrhage Anal stricture Anal fissure Recurrence Anal discharge Incontinence for faeces or gas

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