Anal Rectal Diseases

Anal Abscess
Anal Cancer
Anal Fissure
Anal Warts
Cancer of the Anus
Cancer of the Rectum
Condyloma
Cryptitis
Enlarged Papillae
Fecal Incontinence
Fissure
Fistula-in-ano

Hemorrhoids
Levator Syndrome
Pilonidal Cyst
Polyps
Procidentia
Proctalgia Fugax
Proctitis
Pruritus Ani
Rectal Prolapse
Rectocele
Warts Venereal

Anorectal Anatomy
Arterial Supply

Nerve Supply

Inferior rectal A
middle rectal A

Sympathetic: Superior
hypogastric plexus

Venous drainage
Inferior rectal V
middle rectal V

3 hemorrhoidal
complexes

Parasympathetic:
S234 (nerviergentis

Pudendal Nerve:
Motor and sensory

L lateral
R antero-lateral
R posterolateral

Anal canal

Lymphatic drainage
Above dentate: Inf. Mesenteric
Below dentate: internal iliac

Anal verge

Pain?
-> painless
Bright red bleeding
Prolapse associated
with defecation

Internal

External
Anoderm
Swell, discomfort,
difficult hygiene

Pain?
-> Thrombosed

Anatomy

Haemorrhoids
Back Ground

They are part of the normal

anoderm cushions
They are areas of vascular
anastamosis in a supporting stroma
of subepithelial smooth muscles.
The contribute 15-20% of the normal
resting pressure and feed vital
sensory information .
3 main cushions are found

L lateral
This combination
R anterior
is only in 19%
R posterior

But can be found anywhere in anus

Prevalence is 4%
Miss labelling by referring
physicians and patients is common

Haemorrhoids

Pathogensis
Abnormal haemorrhoids are dilated cushions of arteriovenous
plexus with stretched suspesory fibromuscular stroma with
prolapsed rectal mucosa
3 main processes: 1. Increased venous pressure
2. Weakness in supporting fibromuscular stroma
3. Increased internal sphincter tone
Risk Factors
Habitual
Pathological
1.
2.
3.
4.
5.
6.
7.
8.

Constipation and straining

Low fibre high fat/spicy diet
Prolonged sitting in toilet
Pregnancy
Aging
Obesity
Office work
Family tendency

1.
2.
3.
4.
5.
6.
7.

Chronic diarrhea (IBD)

Colon malignancy
Portal hypertension
Spinal cord injury
Rectal surgery
Episiotomy
Anal intercourse

Haemorrhoids

Classification:
Origin in relation to Dentate line

1.
2.
3.

Internal: above DL
External: below DL
Mixed

Degree of prolapse through anus

1st: bleed but no prolapse

2nd: spontaneous reduction
3rd: manual reduction
4th: not reducable

A:Thrombosed external
B:First-degree internal
viewed through anoscope
C:Second-degree internal
prolapsed, reduced
spontaneously
D:Third-degree internal
prolapsed, requiring
manual reduction
E:Fourth-degree strangulated
internal and thrombosed
external

Reference : Sabiston Textbook of Surgery, 18th Edition

Haemorrhoids

Clinical assessment
History ( Full history required)

Examination

Haemorrhoid directed:
acute/chronic/
Pain
cutaneous
Lump
acute/ sub-acute
Prolapse define grade
Bleeding fresh, post defecation
Pruritis and mucus

Local

General GI:

Digital:

Change in bowel habit

Mucus discharge
Tenasmus/ back pain
Weight loss
Anorexia
Other system inquiry

Inspect for:
Lumps, note colour and
reducability
Fissures
Fistulae
Abscess
Masses
Character of blood and mucus

Perform proctoscopy and

sigmoidoscopy
General abdominal examination

Haemorrhoids

Investigations:
The diagnosis of haemorrhoids is based on
clinical assessment and proctoscopy

Further investigations should be based on a

clinical index of suspicion

Lab: CBC / Clotting profile/ Group and save

Proctography: if rectal prolpse is suspected
Colonoscopy: if higher colonic or sinister pathology is
suspected

Complications
1. Ulceration
2. Thrombosis
3. Sepsis and abscess formation
4. Incontinence

Thrombosed
internal
haemorrhoids

Thrombosed
external
haemorrhoids

Haemorrhoids

Internal H. Treatment :
Conservative Grade 1&2
Measures
Dietary modification: high fibre diet

Stool softeners
Bathing in warm water
Topical creams NOT MUCH VALUE

Minimally
invasive

Indicated in failed medical treatment and grades 3&4

injection sclerotherapy

Rubber band ligation

Laser photocoagulation

Cryotherapy freezing

Stapled haemorrhoidectomy

Surgical

Indications:
1.
Failed other treatments
2.
Severely painful grade 3&4
3.
Concurrent other anal conditions
4.
Patient preference

Haemorrhoids

External H. Treatment :

If presentation less than 72 hours:

Enucleate under LA or GA

Leave wound open to close by secondary intension

Apply pressure dressing for 24 hours post op

If more than 72 hours:

Conservative measures

Perianal Fistula and Abscess

5%

Perianal abscess almost always arise

from a fistulous tract. It is an infection of
the soft tissue surrounding the anus.
Aetiology & Pathogenesis:
4-10 glands at dentate line.
Infection of the cryptglandular epithelium
resulting from obstruction of the glands.
Ascending infection into the intersphincteric
space and other potential spaces.
Bacteria implicated:
E.Coli., Enterococci, bacteroides
Other causes:
Crohn
TB
Carcinoma, Lymphoma and Leukaemia
Trauma
Inflammatory pelvic conditions (appendicitis)

60
%

5%

Ischiorectal
20%

Intersphincteric

suprasphincteric

Trans-sphincteric

extrasphincteric

Pathophysiology
Glandular secretion
stasis

Infection &
suppuration

Anal crypts
obstruction

abscess
formation

Perianal Abscess

Perianal Abscess
Clinical presentation
Abscess

Clinical presentation

Perianal

Perianal pain, discharge (pus) and fever

Tender, fluctuant, erythematous subcutaneous
lump

Ischio-rectal

Chills, fever, ischiorectal pain

Indurated, erythematous mss, tender

Intersphincteric
Supralevator

Rectal pain, chills and fever, discharge

PR tender. Difficult to identify are. EUA needed

Peri-anal Fistula
Clinical presentation

Follow 40-60% of perianal

abscess and cryptgland
infections
Presentation:

External openings
Purulent discharge
Blood
Perianal pain

Also associated with:

IBD
Malignancy
TB/ Actinomycosis
Diverticular disease

Godsalls law
Anterior: drain straight
Posterior: drain curved to anorectal
midline

Perianal Abscess
Management
Aim:

adequate drainage of abscess

preservation of sphincter function
Abscess

Perianal
Ischio-rectal
Intersphincteric
Supralevator

Treatment
Incision and drainge de-roof cavity
pack with gauze and iodine
IV AB, sitz bath tid, laxitives and anlgesia
F/U for fistula
I&D through interspgincteric plane.
Treat the underlying cause

* Preop: full lab evaluation

*Always perform Examination under GA ( EUA) and obtain a biopsy.

Perianal fistula
Managment
Aim:

Define anatomy
Eliminate tract
preservation of sphincter function
Fistula

Perianal

Treatment
Fistulotomy vs fistulectomy

Trans/Extra/Supra Complex treatments using seton

sphincteric

* Preop: full lab evaluation

*Always perform Examination under GA ( EUA) and obtain a biopsy.

Anal Fissure

Linear tears in the anal mucosa exposing the internal sphincter

90% are posterior
Caused mainly by trauma ( hard Stool). Followed by increased
sphincter tone and ischemia.
Other causes: IBD, Ca, Chronic infections

Anal Fissure

Clinical Assessment
Acute
Sever acute
pain
Fresh blood
spotting
Clean linear
tear.

Chronic
Pain mild to
moderate
More than 6
weeks
Hypertrophied
Int.sphincter
Skin tag
Granulation
around the
edge

Anal Fissure

Treatment
Conservative
High fibre diet
Medical
sphincterotomy:
GTN
Ca channel blockers
Butulinum toxins

Surgical
Lateral sphincterotomy

Pilonidal Sinus
Pathogenesis:
A sinus tract at natal cleft resulting from:

Blockage of hair follicle

Folliculitis

Abscess followed by sinus formation.

Hair trapping

Foreign body reaction

The sinus tract is cephald

Associated with:

Caucasians

Hirsute

Sedentary occupations

Obese

Poor hygeine

Presentation & Treatment

Acute

abscess

Incision and drainage

Recurrence: 40%

Chronic

Pain and
discharge

Wide local excision

with primary closure or
closure by secondary
intension
Recurrence: 8-15%

Also found: umbilicus, finger webs, perianal area

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.

Pilonidal sinus

rare before puberty and in people over 40 years.

History
Sex
Hemorrhoids

common in both sexs

Perianal haematomata

occurs at all ages

Fissure-in-ano

common in men

Anorectal abscess

more common in men

Pilonidal sinus

more common in men

Prolapse of rectum

more common in women

History
Principal symptoms of rectal and anal

conditions:
Bleeding
Pain
Tenesmus

Change in bowel habit

Change in the stool
Discharge
pruritis

History - Bleeding
Can be fresh or altered
Example of altered is melaena

Black tarry stool

Recognizable blood may appear in four

ways:
Mixed with faeces
On the surface of the faeces
Separate from the faeces: after/unrelated to

defaecation
On the toilet paper after cleaning

History - Bleeding
Diagnosis of anal conditions which

present with rectal bleeding

Bleeding but no pain:

Blood
Blood
Blood
Blood

mixed with stool = ca of colon

streaked on stool = ca of rectum
after defaecation = hemorrhoids
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.

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

Anorectal examination

One of the most important examinations in a patient with

abdominal disease.
Still its the least popular segment of the entire physical
examination.
Should not be omitted from your examination, especially in
middle-aged and older patient, why?
risks missing an asymptomatic carcinooma

Can be done in numerous positions:

Left Lateral (Sims) position. The usual position when the patient

is in bed. Turn patient on to left side with pelvis vertical. Ask patients
to draw knees up to chest with buttocks on the side of the couch
The Knee-elbow position. Patient kneeling on couch, resting on
elbows, of particular use when palpating the prostate and seminal
The Dorsal Position. This position with the patient lying on the back
with right leg flexed is useful when the patient is in severe pain, and
movement is contra-indicated. Enables assessment of rectovesical
pouch in abdominal emergencies.
Lithotomy. best position for examination but not always available.

Anorectal examination
External inspection:
Piles.
Skin tags (normal, Crohn's, hemorhoids).
Rectal prolapse.
Anal fissure.
Fistula.
Anal warts.
Carcinoma.
Signs of incontinence, diarrhea.

External inspection (straining):

Ask pt. to strain.
Rectal prolapse upon straining.
Hemorrhoid prolapse.
Incontinence.
Ask if straining is painful

Anorectal examination
palpation
Lubricate index finger.
Insert finger slowly, assessing external sphincter tone

as enter.
Male: palpate prostate [anterior of rectum]:
Hard nodule (prostate cancer).
Tender (prostatitis).
Female: palpate cervix [anterior of rectum]:
Mass in pouch of Douglas.
Rotate finger, palpating along left, posterior, right walls.
Withdraw finger.
Wipe lubricant off pt.
Ask if was significant pain during examination.

Anorectal examination
Inspect withdrawn fingertip for:
Blood, melaena
Stool color
Pus
Mucous.

Other examination would be

systemically preformed and depends on

the case you have e.g swelling such as
anorectal abscess or ulcers.

Acute Ano-rectal
Conditions

Rectal prolapse
Rectal prolapse is the abnormal movement of the

rectal mucosa down to or through the anal

opening.

Mucosal prolapse

Complete rectal prolapse

Rectal prolapse
Mucosal prolapse is more often seen in children

below 3 yrs of age following an attack of diarrhoea

or whooping cough , and if it occurs in adult is
usually associated with haemrrhoids.
Complete rectal prolapse is seen more commonly in
elderly women who have a habit of excessive
straining during defecation.
Rectal prolapse is often associated with other conditions

such as:
* Pinworms(Enterobiasis)
* Cystic fibrosis
* Malnutrition and malabsorption (Celiac disease)
* Constipation
* Prior trauma to the anus or pelvic area

Rectal prolapse
Symptoms:The main symptom is a protrusion of a reddish
mass from the anal opening, especially following a bowel
movement.
Treatment :

* Treating the underlying condition

* In children, Conservative treatment
* The rectal mass may be returned to the rectum manually
* Surgical correction for complete rectal prolapse

Complications

* Constipation
* Malnutrition or malabsorption
* Other complications of underlying condition

Proctitis
An inflammation of the rectum causing discomfort,

bleeding, and occasionally, a discharge of mucus or pus,

And the anus may also be involved.
Causes:

Sexually-transmitted diseases(gonorrhea, herpes,

Syphilis ,chlamydia, and lymphogranuloma venereum.
* Non-sexually transmitted infections( Beta-hemolytic
streptococcus , Amoebic dysentry, Bilharzial dysentry)
*Autoimmune diseases (Ulcerative colitis and crohns
disease)
* Tuberculous proctitis
* AIDS
*Radiation Proctitis
* noxious agents

Proctitis
Symptoms:
pain, discomfort
rectal bleeding
rectal discharge, pus
stools, bloody
constipation
Tenesmus

*Tests:
proctoscopy
sigmoidoscopy
rectal culture

Proctitis
Treatment: treatment of the underlying

cause usually cures the problem. Proctitis

caused by infection is treated with antibiotics
specific for the causative organism.
Corticosteroid or mesalamine suppositories
may relieve symptoms in Crohn's disease or
ulcerative colitis.

Benign tumours of the

rectum

A polyp is a lesion that projects into the lumen

Polyps are commonly found

(POLYPS)
in vascular organs
Polyps bleed easily
The rectum and sigmoid colon
are common sites of polyps
Symptoms and signs of polyps
* passage of blood and
mucus PR
* Rarely obstruction or
intussusception

Types of Polyps
Juvenile Polyps
Commonest form of polyps in children
Are red pedunculated spheres lesions

Can occur throughout large bowel but

are most common in the rectum

Usually present before 12 years
Present with Prolapsing lump or rectal
bleeding
Have little malignant potential
Treated by local endoscopic resection

Adenomatous Polyps
Are pedunculated lesions
Mainly occur in the rectum and sigmoid

colon
Are often asymptomatic but may produce
anaemia from chronic occult bleeding
May give rise to crampy pain
May secrete mucus
Have malignant potential
Treated by colonoscopic polypectomy

Villous Papillomas
Are flat, sessile lesions within the rectum
Secrete copious amount of mucus

producing spurious diarrhoea

Present with hypokalemia
Significant risk of malignant change
Treated by transanal excision of complete
lesion
If lesion is extensive, mucosal
proctectomy and coloanal anastomosis
should be done

Familial Polyposis
Is an autosomal dominant syndrome

diagnosed when a patient has more than 100

adenomatous polyps
Due to mutation on long arm of chromosome 5
May be asymptomatic but bleeding,,
abdominal pain and diarrhoea are all likely
symptoms
The risk of devoloping carcinoma is virtually
100%
within 15 years
The most appropriate treatment is
panproctocolectomy
with ileal pouch-anal anastomosis