benign anorectal diseases dr jamal hamdi. content haemorrhoids anorectal abscess anal fistula anal...

Benign Anorectal DiseasesBenign Anorectal Diseases

Dr Jamal HamdiDr Jamal Hamdi

ContentContent

HaemorrhoidsHaemorrhoids

Anorectal AbscessAnorectal Abscess

Anal fistulaAnal fistula

Anal fissureAnal fissure

Benign Anal TumorsBenign Anal Tumors

Rectal ProlapseRectal Prolapse

Pilonidal SinusPilonidal Sinus

ProctitisProctitis

Pruritis AniPruritis Ani

Anatomy of the RectumAnatomy of the Rectum

Length:Length: 12 cm. 12 cm.

Diameter:Diameter: Upper part Upper part same of sigmoid same of sigmoid (4cm) but lower is dilated (rectal ampulla).(4cm) but lower is dilated (rectal ampulla).

Beginning:Beginning: rectosigmoid junction (sacral rectosigmoid junction (sacral promontory).promontory).

End:End: 2.5 cm below and in front of the tip of 2.5 cm below and in front of the tip of coccyx.coccyx.

Anatomy of rectumAnatomy of rectumMaleFemale

AnteriorBladderSeminal vesicles

UretersProstateUrethra

Pouch of douglasUterusCervix

Posterior vaginal wall

LateralLateral ligMiddle rectal A.

Obturator internus MSide wall of pelvis

Levator ani M

Lateral ligMiddle rectal A.

Obturator internus MSide wall of pelvis

Levator ani M

PosteriorSacrum and coccyxLoose areolar tissueFacial condensation

Superior rectal ALymphatics

Sacrum and coccyxLoose areolar tissueFacial condensation

Superior rectal ALymphatics

Anatomy of rectumAnatomy of rectum

Arterial SupplyArterial Supply

Superior rectal artery (chief artery)Superior rectal artery (chief artery)

Middle rectal arteryMiddle rectal artery

Median Sacral arteryMedian Sacral artery

Anatomy of Anal CanalAnatomy of Anal Canal

Length:Length: 4 cm 4 cmExtent:Extent: from anorectal from anorectal

junction to the anus.junction to the anus.Interior:Interior:

Upper part:Upper part:Anal columnAnal columnAnal valveAnal valveAnal sinusAnal sinusDentate lineDentate line

Middle part:Middle part:Lower Part:Lower Part:

Anatomy of Anal CanalAnatomy of Anal Canal

Musculature:Musculature:1.1. External anal sphincterExternal anal sphincter

2.2. Internal anal sphincterInternal anal sphincter

Arterial supply:Arterial supply:– Superior and inferior Superior and inferior

rectal arteries.rectal arteries.

Venous Drainage:Venous Drainage:

Lymphatic Drainage.Lymphatic Drainage.

Clinical Features of Anorectal Clinical Features of Anorectal DiseaseDisease

1.1. Bleeding.Bleeding.

2.2. Pain.Pain.

3.3. Altered bowel habit.Altered bowel habit.

4.4. Discharge.Discharge.

5.5. Tenesmus.Tenesmus.

6.6. Prolapse.Prolapse.

7.7. Pruritis.Pruritis.

8.8. Loss of weightLoss of weight

InvestigationsInvestigations

ProctoscopeProctoscopeInspect (10-12 cm)Inspect (10-12 cm)Biopsy can be takenBiopsy can be taken

Sigmoidoscope Sigmoidoscope Lighted tube 2 cm in diameter.Lighted tube 2 cm in diameter.20 to 25 cm long.20 to 25 cm long.Reaches 20 to 25 cm from the dentate line.Reaches 20 to 25 cm from the dentate line.20 to 25 % of colorectal tumors.20 to 25 % of colorectal tumors.Safe and effective for screening low-risk adults Safe and effective for screening low-risk adults under 40 years of age.under 40 years of age.An enema is sometimes used to prepare the An enema is sometimes used to prepare the patient before the examination.patient before the examination.

InvestigationInvestigation

Flexible sigmoidoscopeFlexible sigmoidoscope

A fiberoptic scope.A fiberoptic scope.

Measures 60 cm in length.Measures 60 cm in length.

Reach the proximal left colon or even the splenic Reach the proximal left colon or even the splenic flexure.flexure.

50 % of colorectal cancers.50 % of colorectal cancers.

Every 5 years beginning at age 50 is the current Every 5 years beginning at age 50 is the current endoscopic screening method recommended for endoscopic screening method recommended for asymptomatic persons at average risk for colorectal asymptomatic persons at average risk for colorectal carcinoma.carcinoma.

HemorrhoidsHemorrhoids

DefinitionDefinition– InternalInternal– ExternalExternal– Interno-ExternalInterno-External

SitesSites

1.1. Left lateral (3 o’clock).Left lateral (3 o’clock).

2.2. Right posteriolateral (7 o’clock).Right posteriolateral (7 o’clock).

3.3. Right anterolateral (11 o’clock).Right anterolateral (11 o’clock).

HemorrhoidsHemorrhoids

ClassificationClassification

1.1. 11stst degree degree

2.2. 22ndnd degree. degree.

3.3. 33rdrd degree. degree.

4.4. 44thth degree. degree.

How hemorrhoids causes bleeding?How hemorrhoids causes bleeding?

HemorrhoidsHemorrhoids

DiagnosisDiagnosis

ComplicationComplication

Treatment of HemorrhoidTreatment of Hemorrhoid

11stst degree degree

ConservativeConservative

Dietary adviseDietary advise

Bulk laxativesBulk laxatives

Sitz bathSitz bath

Treatment will be effective at 6 monthTreatment will be effective at 6 month

Treatment of hemorrhoidsTreatment of hemorrhoids

22ndnd degree degree

Rubber band ligation.Rubber band ligation.

Complication of band Complication of band – HemorrhageHemorrhage– SepsisSepsis– PainPain

33rdrd degree degree– HemorrhoidectomyHemorrhoidectomy

Treatment of hemorrhoidsTreatment of hemorrhoids

Complication of hemorrhoidectomyComplication of hemorrhoidectomyAcute urinary retentionAcute urinary retentionSecondary hemorrhageSecondary hemorrhageAnal stenosisAnal stenosis

Thrombosed hemorrhoidThrombosed hemorrhoidConservative (laxative, analgesic, ice Conservative (laxative, analgesic, ice packs)packs)Operative manual dilatation of the anus Operative manual dilatation of the anus and hemorrhoidectomyand hemorrhoidectomy

Anorectal AbscessAnorectal Abscess

Definition: Infection in one or more of anal Definition: Infection in one or more of anal spaces, usually is bacterial infection of spaces, usually is bacterial infection of blocked anal gland at dentate line.blocked anal gland at dentate line.

OrganismsOrganisms– EcoliEcoli– Staph aureus.Staph aureus.

Anorectal AbscessAnorectal Abscess

SitesSites

1.1. Perianal.Perianal.

2.2. Ischiorectal.Ischiorectal.

3.3. Pelvirectal.Pelvirectal.

4.4. Intersphincteric.Intersphincteric.

Increase incidence with?Increase incidence with?

Anorectal AbscessAnorectal Abscess

HistoryHistory

Age, sex, symptomsAge, sex, symptoms

Examination:Examination:

PositionPosition

TendernessTenderness

Color / tempColor / temp

Shape, size, compositionShape, size, composition

Lymph drainageLymph drainage

Local tissueLocal tissue

General ExaminationGeneral Examination

Anorectal AbscessAnorectal Abscess

InvestigationInvestigation

TreatmentTreatment

Incisional and drainageIncisional and drainage

AntibioticsAntibiotics

Fissure-in-ano (anal fissure)Fissure-in-ano (anal fissure)

Definition:Definition:

Acute & chronicAcute & chronic

Longitudinal split in the skin of the anal Longitudinal split in the skin of the anal canal.canal.

Common sites:Common sites:– Midline 6 and 12 o’clock.Midline 6 and 12 o’clock.

Rarely associated with crohns, HSV, HIV.Rarely associated with crohns, HSV, HIV.

Fissure-in-anoFissure-in-anoDiagnosisDiagnosis

TreatmentTreatment

Non- operativeNon- operative– Stool softeners and laxatives Stool softeners and laxatives – Improve hygiene.Improve hygiene.– Anesthetic suppositories may be helpful.Anesthetic suppositories may be helpful.

OperativeOperative– Anal dilation.Anal dilation.– Lateral internal sphincterotomyLateral internal sphincterotomy– Fissurectomy and midline sphincterotomy.Fissurectomy and midline sphincterotomy.

Anal FistulaAnal Fistula

DefinitionDefinition

secondary to crohn’s, TB, CA of rectum or secondary to crohn’s, TB, CA of rectum or lymphogranuloma.lymphogranuloma.

S/SS/S– Watery or purulent discharge from the Watery or purulent discharge from the

external opening of fistulaexternal opening of fistula– Recurrent episode of pain.Recurrent episode of pain.– Pruritis.Pruritis.

ProctitisProctitis

CauseCause– NonspecificNonspecific– Ulcerative proctocolitisUlcerative proctocolitis– Crohn’s diseaseCrohn’s disease– InfectionInfection

Clostridium difficileClostridium difficileBacillary dysenteryBacillary dysenteryTB proctitisTB proctitisSyphilisSyphilisGonococcalGonococcal

ProctitisProctitisNonspecific proctitis Nonspecific proctitis

is an inflammatory condition affecting the is an inflammatory condition affecting the mucosa and, to a lesser extent, the mucosa and, to a lesser extent, the submucosa, confined to the terminal submucosa, confined to the terminal rectum and anal canal.rectum and anal canal. It is the most common variety.It is the most common variety.

Aetiology. Aetiology. This is unknown.This is unknown.The most acceptable hypothesis: It is a The most acceptable hypothesis: It is a limited form of ulcerative colitis (although limited form of ulcerative colitis (although actual ulceration is often not present).actual ulceration is often not present).

ProctitisProctitis

Clinical featuresClinical features

Middle-aged.Middle-aged.

Slight loss of blood in the motions.Slight loss of blood in the motions.

Diarrhoea Diarrhoea

On rectal examination, the mucosa feels warm On rectal examination, the mucosa feels warm and smooth. Often there is some blood on the and smooth. Often there is some blood on the examining finger.examining finger.

Proctoscopic and Sigmoidoscopic examination:Proctoscopic and Sigmoidoscopic examination:– Inflamed mucous membrane of the rectum, but Inflamed mucous membrane of the rectum, but

usually no ulceration. The mucosa above this level usually no ulceration. The mucosa above this level being quite normal.being quite normal.

ProctitisProctitis

TreatmentTreatment

Self-limiting.Self-limiting.

Sulphasalazine (Salazopyrin).Sulphasalazine (Salazopyrin).

Prednisolone retention enemas.Prednisolone retention enemas.

Severe cases Severe cases oral steroids. oral steroids.

Rarely Rarely surgical treatment (last resort) surgical treatment (last resort)

Pruritis aniPruritis ani

Definition: Perianal itching, particularly the Definition: Perianal itching, particularly the frequent and distressing one.frequent and distressing one.

EtiologyEtiology

SymptomsSymptoms

TreatmentTreatment

Rectal ProlapseRectal Prolapse

Definition: Eversion of whole thickness of Definition: Eversion of whole thickness of the lower part of rectum and anal canal.the lower part of rectum and anal canal.

TypesTypes

1.1. Partial prolapse.Partial prolapse.

2.2. Complete prolapse.Complete prolapse.

CauseCause

Predisposing factorsPredisposing factors

Differential diagnosisDifferential diagnosis

Rectal ProlapseRectal Prolapse

HistoryHistory

Age.Age.

Sex.Sex.

Symptoms.Symptoms.

ExaminationExamination

Rectal ProlapseRectal Prolapse

TreatmentTreatment

PartialPartial– InfantInfant– AdultAdult

Complete (Thiersch wire).Complete (Thiersch wire).

Pilonidal sinusPilonidal sinus

Definition: Sinus which contain tuft of Definition: Sinus which contain tuft of hairs, mainly in skin covering the sacrum hairs, mainly in skin covering the sacrum and coccyx but can occur between fingers, and coccyx but can occur between fingers, in hair dressers, and the umbilicus.in hair dressers, and the umbilicus.

EtiologyEtiology

SymptomsSymptoms

TreatmentTreatment– Acute abscessAcute abscess– Chronic abscessChronic abscess

Benign Anal TumorsBenign Anal Tumors

Villous AdenomaVillous Adenoma

Tubular PolypsTubular Polyps