Download - Anorectal Diseases
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Anorectal Diseases
Supervised By
Dr Jamal Hamdi
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References
Baily and Love’s “Short Practice of Surgery 23rd Edition”
Norma L. Browse “An introduction to the symptoms and Signs of Surgical Disease, 3rd edition”
Fathy Ahmed State “Anatomy of Pelvis and Perineum”
Kaley E. Rarey “Human Anatomy” CD.
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Content
Anatomy of rectum Anatomy of Anal Canal Clinical Manifestation of anorectal disease Anorectal Examination Investigation
Ahmad Saad Zahrani
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Content
Case Scenario I Case Scenario II Case Scenario III Anal fissure Proctitis
Raef Ahmad Qutub
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Content
Anorectal Abscess Anal fistula Rectal Prolapse Pilonidal Sinus Pruritis Ani Anal Neoplasm
Mulham Fowad Qurani
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Anatomy of the Rectum
Length: 12 cm. Diameter: Upper part same of sigmoid
(4cm) but lower is dilated (rectal ampulla). Beginning: rectosigmoid junction (sacral
promontory). End: 2.5 cm below and in front of the tip of
coccyx. Difference b/w rectum and large intestine?
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Anatomy of rectumMale Female
Anterior Bladder
Seminal vesicles
Ureters
Prostate
Urethra
Pouch of douglas
Uterus
Cervix
Posterior vaginal wall
Lateral Lateral lig
Middle rectal A.
Obturator internus M
Side wall of pelvis
Levator ani M
Lateral lig
Middle rectal A.
Obturator internus M
Side wall of pelvis
Levator ani M
Posterior Sacrum and coccyx
Loose areolar tissue
Facial condensation
Superior rectal A
Lymphatics
Sacrum and coccyx
Loose areolar tissue
Facial condensation
Superior rectal A
Lymphatics
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Anatomy of rectum
Arterial Supply Superior rectal artery (chief artery) Middle rectal artery Median Sacral artery
Venous Drainage Internal rectal venous plexus External rectal venous plexus
Lymphatic: Upper ½ Lower ½
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Anatomy of Anal Canal
Length: 4 cmExtent: from anorectal
junction to the anus.Interior: Upper part:
Anal column Anal valve Anal sinus Dentate line
Middle part: Lower Part:
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Anatomy of Anal Canal
Musculature:1. External anal sphincter
2. Internal anal sphincter
Arterial supply: Superior and inferior
rectal arteries.
Venous Drainage: Rectal venous plexus
Lymphatic Drainage.
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Clinical Features of Anorectal Disease
1. Bleeding.
2. Pain.
3. Altered bowel habit.
4. Discharge.
5. Tenesmus.
6. Prolapse.
7. Pruritis.
8. Loss of weight
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Bleeding
Bleeding
With Feces Without Feces
Mixed (proximal to sigmoid
colon)
On the surface(Distal to sigmoid
Colon)
Separate from feces(follow defecation or
Not)
On toilet paper(anal skin)
The color of blood Bright red anal or rectum Dark proximal lesion in the large bowel or higher.
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Clinical Features
Pain Painful or not?
Painless Hemorrhoids and rectal Ca. Painful anal fissure, abscess
Altered Bowel Habits Spurious diarrhea
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Clinical Features
Discharge Mucus or pus
Tenesmus “ I feel I want to go but nothing happens”
Prolapse Pruritis
Secondary to a rectal discharge
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Anorectal Examination
Preparation Position of the patient Equipment
Inspection Skin rashes Fecal soiling, blood or mucus. Scars or fistula. Lumps. Ulcers especially fissures.
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Anorectal Examination
Palpation Anal Canal. Rectum. Rectovesico/rectouterine pouch
Prostate and seminal vesicles Cervix and uterus
Bimanual examination.
Your finger.
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Investigations
Proctoscope Inspect (10-12 cm) Biopsy can be takenProctosigmoidoscope Lighted tube 2 cm in diameter. 20 to 25 cm long. Reaches 20 to 25 cm from the dentate line. 20 to 25 % of colorectal tumors. Safe and effective for screening low-risk adults
under 40 years of age. An enema is sometimes used to prepare the patient
before the examination.
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Investigation
Sigmoidoscope 18 cm Inspect
Flexible sigmoidoscope A fiberoptic scope. Measures 60 cm in length. Reach the proximal left colon or even the splenic flexure. 50 % of colorectal cancers. Every 5 years beginning at age 50 is the current
endoscopic screening method recommended for asymptomatic persons at average risk for colorectal carcinoma.
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Common Anorectal Disease PART I
Presented By Raef Qutub
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Case Scenario I
32 years old Saudi male, complaining of painless bleeding per rectum and a palpable lump after defecation. Pt sometimes has mucus discharge and pruritis in the perianal area
What other questions you want to ask? And why?
What are D/D of painless bleeding per rectum?
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Scenario I
What is your provisional Diagnosis?
What are the investigations you need and why?
What is the most common complication in such pt?
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Hemorrhoids
Definition Internal External
Sites
1. Left lateral (3 o’clock).
2. Right posteriolateral (7 o’clock).
3. Right anterolateral (11 o’clock).
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Hemorrhoids
Classification
1. 1st degree
2. 2nd degree.
3. 3rd degree.
4. 4th degree.
How hemorrhoids causes bleeding?
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Hemorrhoids
Diagnosis
Complication
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Treatment of Hemorrhoid
1st degree
Conservative Dietary advise Bulk laxatives Sitz bath Treatment will be effective at 6 month
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Treatment of hemorrhoids
2nd degree Rubber band ligation. Complication of band separates
Hemorrhage Sepsis Pain
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Treatment of hemorrhoids
3rd degree Hemorrhoidectomy
Complication of hemorrhoidectomy Acute urinary retention Secondary hemorrhage Anal stenosisThrombosed hemorrhoid Conservative (laxative, analgesic, ice packs) Operative manual dilatation of the anus and
hemorrhoidectomy
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Case Scenario II
35 years old, male pt, complaining of anal pain which begins gradually increase in severity over hours and subsides spontaneously over 5 days. It is continuous discomfort, also, he has lump which is gradually enlarged and become painful.
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Case Scenario II
O/E There are 2 lumps around the anal margin. The skin
is not edematous and the lump has a deep red-purple color, they are tender spherical shape, 1 cm in diameter, hard in consistency, LN not enlarged.
What is your provisional Dx? What is the susceptible complication? What is the treatment? If seen within 24hr of the onset, the blood clot can
be evacuated under local anesthesia
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Case Scenario III
18 years old, male pt, complain of anal pain which begins during defecation and persists for minutes after defecation, it is severe, pt becomes frightened to defecate and the pain makes him more constipated, pt has little amount of bleeding.
There is splitting of anal skin in the midline. Anal sphincter is spasm. What is your diagnosis? What is your treatment?
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Fissure-in-ano (anal fissure)
Definition: Acute & chronic Longitudinal split in the skin of the anal canal. Common sites:
Midline 6 and 12 o’clock.
Rarely associated with crohns, HSV, HIV.
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Fissure-in-ano
Diagnosis Treatment Non- operative
Stool softeners and laxatives to relieve straining. Improve hygiene. Anesthetic suppositories may be helpful.
Operative Anal dilation. Lateral internal sphencterotomy Fissurectomy and midline sphencterotomy.
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Proctitis
Cause Nonspecific Ulcerative proctocolitis Crohn’s disease Infection
Clostridium difficile Bacillary dysentery TB proctitis Syphilis Gonococcal
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Proctitis
Nonspecific proctitis is an inflammatory condition affecting the
mucosa and, to a lesser extent, the submucosa, confined to the terminal rectum and anal canal.
It is the most common variety. Aetiology. This is unknown. The most acceptable hypothesis: It is a
limited form of ulcerative colitis (although actual ulceration is often not present).
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Proctitis
Clinical features Middle-aged. Slight loss of blood in the motions. Diarrhoea On rectal examination, the mucosa feels warm and
smooth. Often there is some blood on the examining finger.
Proctoscopic and Sigmoidoscopic examination: Inflamed mucous membrane of the rectum, but usually no
ulceration. The mucosa above this level being quite normal.
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Proctitis
Treatment Self-limiting. Sulphasalazine (Salazopyrin). Prednisolone retention enemas. Severe cases oral steroids. Rarely surgical treatment (last resort)
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Common Anorectal Disease PART II
Mulham Qurani
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Anorectal Abscess
Definition: Infection in one or more of anal spaces, usually is bacterial infection of blocked anal gland at dentate line.
Organisms Ecoli Staph aureus.
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Anorectal Abscess
Sites
1. Perianal.
2. Ischiorectal.
3. Pelvirectal.
4. Intersphincteric.
Increase incidence with?
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Anorectal Abscess
History Age, sex, symptoms
Examination: Position Tenderness Color/temp Shape, size, composition Lymph drainage Local tissue General Examination
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Anorectal Abscess
Investigation
Treatment Incisional and drainage
Antibiotics
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Anal Fistula
Definition 50% secondary to crohn’s, TB, CA of rectum
or lymphogranuloma. S/S
Watery or purulent discharge from the external opening of fistula
Recurrent episode of pain. Pruritis.
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Rectal Prolapse
Definition: Eversion of whole thickness of the lower part of rectum and anal canal.
Types
1. Partial prolapse.
2. Complete prolapse. Cause Predisposing factors Differential diagnosis
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Rectal Prolapse
History Age. Sex. Symptoms.
Examination
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Rectal Prolapse
Treatment Partial
Infant Adult
Complete (Thiersch wire).
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Pilonidal sinus
Definition: Sinus which contain tuft of hairs, mainly in skin covering the sacrum and coccyx but can occur between fingers, in hair dressers, and the umbilicus.
Etiology Symptoms Treatment
Acute abscess Chronic abscess
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Pruritis ani
Definition: Perianal itching, particularly the frequent and distressing one.
Etiology
Symptoms
Treatment
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Anal Neoplasm
Epidermoid carcinoma Most common Type of cell Prone to HPV infection. Presented with. Treatment of choice.
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Anal Neoplasm
Malignant melanoma of anal margin
3rd common site. Course. Treatment of choice. Survival rate.