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ANORECTAL DISEASES
Bernard M. Jaffe, MDProfessor of Surgery, Emeritus
Tulane University School of Medicine
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ANAL CANAL• Borders- Coccyx• Ischiorectal Fascia Bilaterally• Female- Perineal Body; Male-
Urethra• Disorders Common and Generally Benign• BUT • Painful and Disabling• Divided Into Upper and Lower Segments
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UPPER VS. LOWER UPPER• Above Dentate Line
(Marked by Anal
Valves)• Pleated, Folded Mucosa• 12-14 Columns of
Morgagni• Anal Crypts Between
Columns• Cuboidal Epithelium
LOWER
• Below Dentate Line
• Smooth Mucosa• Absent
• Absent• Squamous Epithelium
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ANAL SKIN• Continuous with Anal Canal• Contains Apocrine Glands• Site of Hydradenitis Suppurativa• Pain Receptors (Not Stretch)• Lesions Drain to Inguinal Nodes
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VASCULAR• Arterial Supply• Bilateral, Duplicated• Middle and Inferior Hemorrhoidal
Arteries Off Internal Iliac• Venous Drainage• Bilateral, Duplicated• Internal Iliac Veins to Inferior Vena
Cava
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ANAL MUSCULATURE• One Tubular Structure Inside Another• Inner- Continuation of Rectal Circular Layer• Extends 1.5cm Beyond Dentate Line• Involuntary • Forms Internal Sphincter• Outer- Continuous Sheet of Striated Muscle
of Pelvic Floor• External Sphincter• Voluntary Control
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HEMORRHOIDS• Abnormal Anal Cushions• Cushions Contain Blood Vessels,
Smooth Muscle, Elastic and Connective Tissue
• Left Lateral, Right Anterior, Right Posterior Positions
• Unknown Causes, Includes Straining• Common During Pregnancy
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EXTERNAL HEMORRHOIDS• Covered by Anoderm• Distal to Dentate Line• Swell, Causing Discomfort, Difficult
Hygiene• Sever Pain Only with Thrombosis
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INTERNAL HEMORROIDS• Cause Painless Bright Red Bleeding• Prolapse with Defecation• Mucus Secretion• Itching • Pain is Rare (No Mucosal
Pain Receptors)
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HEMORRHOID GRADES• 1◦ Bleeding Diet• 2◦ Prolapse, Bleeding Rubber Band Ligation• 3◦ Prolapse with Hemorrhoidectomy or• Digital Reduction, or Rubber Band
Bleeding Ligation• 4.◦ Strangulation Urgent
Hemorrhoidectomy
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OFFICE TREATMENT• Dietary Management (for All Grades)• Fiber Supplements• Local Hygiene• Avoidance of Straining• Medication to Soften Stool• More Extensive- Rubber Band
Ligation
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HEMORRHOIDECTOMY• Indications• Failure of Conservative Measures• Prolapse Requiring Manual Reduction• Strangulation• Ulceration• Commonest Complications• Bleeding• Urinary Retention
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ANAL FISSURES• Almost Always Directly Posterior• If Not- STD’s, Crohn’s, Hydradenitis• Associated Findings-• Sentinal (External) Pile• Enlarged Anal Papilla• Causes Pain, Mild Bleeding• Responds to Sitz Baths, Bulking Agents
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ABCESSES• Originate in Intersphincteric Plane • Usually From Anal Gland• If Progress Downward to Skin Causes
Perineal Abcess• If Progresses to Other Sites• More Complicated• Harder to Treat
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OTHER SITES OF ABCESS• Intermuscular- Vertical Tracking• Supralevator- Vertical Tracking• Tough to Diagnose• Ischiorectal- Horizontal Tracking• Horseshoe- Circumferential Tracking
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ABCESS TREATMENT• Drainage is Critical• Superficial Abcess- Office Drainage• Attempt to Localize Site of Origin
Within the Anal Lumen • Needle Localization or CT Imaging
May Be Necessary to Localize More Complex Abcesses
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OPERATIVE DRAINAGE• OR Required for • Complex (Horeshoe Abcess)• High (Supralevator) Abcess• Immunocompromised
Patients• Patients With Systemic
Symptoms
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FISTULA-IN-ANO• Complicates Anorectal Sepsis in 25% • Originates in Dentate Line in Anal Canal• Presents With Purulent Peri-Anal Drainage• Punctate Indurated Papule
With Opening• Inner Opening Identified by Probing at
Dentate Line from Drainage Site• May Have Multiple External Drainage
Openings
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TYPES OF FISTULAS• Type 1- Intersphincteric• Treated by Fistulotomy• Type 2- Transsphincteric• Type 3- Supersphincteric• Type 4- Extrasphincteric• Latter 3 Treated With Seton
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SETON• Monofilament Nylon or Rubber Band• Passed Through Fistulous Tract• Causes Fibrosis and Allows Later (8-12
Weeks) Sphincterotomy Without Loss of Continence
• Cutting (Progressively Tightening) Seton Also Acceptable Technique
• Difficult Fistulas- Sliding Flap of Mucosa, Submucosa, and Muscle to Cover Internal Opening
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DIFFICULT FISTULAS• Sliding Flap of Mucosa, Submucosa,
and Muscle to Cover Internal Opening• Injection of Fibrin Glue Into Opening• Even With Multiple Openings, There
is Generally Only One Internal Opening
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PILONIDAL SINUS• Midline Sacrocoxxygeal Skin• Acute Abcess• Chronic Sinuses • Rarely Confused With Fistula-in-Ano• Related to Hair, Penetration of
Granulation Tissue Into Sinuses• Disease of Young People• Treated by Excision
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CONDYLOMA ACCUMINATUM
• Peri-Anal Wart• Caused by Human Papilloma Virus• Associated With AIDS, Anal Intercourse• Difficult to Eradicate- Cautery• Podophyllin• Significant Risk of Epidermoid
Carcinoma
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HYDRADENITIS SUPPURATIVA • Chronic Inflammatory Process• Occurs in Peri-Anal Area and Other Hair-
Bearing Areas • Most Likely Theory- Debris Occludes
Apocrine Gland →Purulence → Rupture→ Subqu Infection
• Organisms- Strep milleri, Staph aureus, epidermitis, and hominis
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TREATMENT• Antibiotics• Drainage, Debridement• Fistulotomy (Distal to Dentate Line)• Wide Local Excision With Skin Graft• Difficult to Eradicate• 30% Recurrence Rate• Association With Squamous
Carcinoma
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CROHN’S DISEASE• Anorectal Disease in 20%• Jeopardizes Continence 2◦ Inflammation• Causes Fissures, Abcesses, Fistulas• Fistulas Proximal to Dentate Line• Can Be First Manifestation of Disease• Symptoms- Pain, Bleeding, Soilage, Poor
Continence
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TREATMENT• CONSERVATIVE MANAGEMENT• Treat Ileal Crohn’s Dsiease• Sitz Baths, Stool Softeners, Analgesics• Steroids, 6 M-P, Azothiaprine,
Cyclosporine• Avoid Fistulotomy- If Needed, Use Seton• Difficult to Manage- Non-Resposive• Often Extensive
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EPIDERMOID CARCINOMA• Anal mass With Bleeding, Pruritis• Epidermoid, Basaloid, Cloacogenic,
Mucoepidermoid Types • <3cm in Size• 25% Superficial or in Situ• 71% Deep Penetration, 25%Node
Positive, 6% Distal Metastases• Increased Frequency in AIDS•
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TREATMENT• Superficial Lesions <2cm- Local Excision• Remainder- Nigro Protocol (Radiation, 5-FU,
Mitomycin)• Almost All Respond and
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TREATMENT• Superficial Lesions <2cm- Local Excision• Remainder- Nigro Protocol (Radiation, 5-
FU, Mitomycin)• Almost All Respond and Disappear• APR for Failure of Nigro Protocol• Contraindication to RT, Chemo• Deep Invasion• Aggressive Lesion