Ano-Rectal Ano-Rectal DiseasesDiseases

BYBY

PROF/GOUDA ELLABBANPROF/GOUDA ELLABBAN

Index Index

Anatomy Anatomy

Physiology of DefecationPhysiology of Defecation

Ano-rectal examAno-rectal exam

Anal PainAnal Pain

Anal BleedingAnal Bleeding

Piles (Haemorrhoids) Piles (Haemorrhoids)

FistulaFistula

Pilonidal SinusPilonidal Sinus

Anatomy of Ano-Anatomy of Ano-rectamrectam

Physiology of Physiology of DefecationDefecation

1. What are the components 1. What are the components of defecation reflex?of defecation reflex?

1.Strech receptor “rectum”

2. Sensory

3. Spinal cord sacral segment

5. rectum, sigmoid colon and internal sphincter “smooth muscle”

4. Motor “Parasympathetic”

2. How defecation reflex is 2. How defecation reflex is initiated?initiated?

New meal in stomach

Parasympathetic

Gastrin

Mass movement shift fecal content to rectum

Triggers defecation reflex

How can an adult prevent How can an adult prevent urge to defecate?urge to defecate?

Cerebral cortex

Tone of external anal sphincter ”skeletal muscle”

Contraction of external anal canal

Prevent defecation

How an increase in How an increase in intraabdominal pressure is intraabdominal pressure is brought about during act of brought about during act of

defecationdefecationCerebral cortex Relaxation of

external anal sphincter

Defecation reflex

Contraction of abdominal muscle

Increase in abdominal pressure

Defecation

Anal PainAnal Pain

Anal Pain:Anal Pain:

-Protracted, cramping and distressing pain -Protracted, cramping and distressing pain

-Presence of pain is extremely significant -Presence of pain is extremely significant because we usually exclude haemorrhoids because we usually exclude haemorrhoids and cancerand cancer

-Annular lesions cause rectal obstruction -Annular lesions cause rectal obstruction and and

Lower abdominal colicLower abdominal colic

-Excessive stretching ; Sharp, splitting pain-Excessive stretching ; Sharp, splitting pain

Conditions present with Conditions present with anal painanal pain

A- Pain alone:A- Pain alone:

Proctalgia fugax Proctalgia fugax

Severe, sharp, shooting electrifying Severe, sharp, shooting electrifying pain, comes spontaneously, usually pain, comes spontaneously, usually at night with no known cause, and at night with no known cause, and not relieved by anythingnot relieved by anything

B- Pain and bleeding:B- Pain and bleeding:

-Fissure in ano -Fissure in ano

It is longitudinal split in the skin of the anal It is longitudinal split in the skin of the anal canal. canal. It reopens every time the patient It reopens every time the patient defecates because defecates because of constipation and high of constipation and high sphincter tone. sphincter tone.

There are two types of fissuresThere are two types of fissures

1.Acute :- Split once causing pain and 1.Acute :- Split once causing pain and heal.heal.

2.Chronic :- Repeated splits causing pain 2.Chronic :- Repeated splits causing pain and and Fibrosis.Fibrosis.

C- Pain and Lump:C- Pain and Lump:1.Perianal hematoma:1.Perianal hematoma:

-Large thrombus in a vein of the -Large thrombus in a vein of the subcutaneoussubcutaneous peri-anal plexus. peri-anal plexus.

-Very bulky hard stool or sudden change -Very bulky hard stool or sudden change in the in the sphincter tone as in “Diarrhea” sphincter tone as in “Diarrhea” cause excessive cause excessive stretching of the anus. stretching of the anus.

-It can be caused by straining and -It can be caused by straining and stretching of the stretching of the perineum during the perineum during the second stage of labor.second stage of labor. Thrombus ; Inflammation ; Pain ; Thrombus ; Inflammation ; Pain ; Oedema Oedema

2.Anorectal Abcess:2.Anorectal Abcess:-Site:-Site:Sub-mucous, inter-sphincteric or ischio-Sub-mucous, inter-sphincteric or ischio-

rectal rectal -The infection begins in an anal gland -The infection begins in an anal gland

from from which the pus tracks. which the pus tracks.-The pain is throbbing, more on sitting, -The pain is throbbing, more on sitting,

moving and defecation. moving and defecation.-The patient may feel a tender swelling -The patient may feel a tender swelling

close close to the anus. to the anus. - There may be fever - There may be fever

D-Pain, Lump and Bleeding:D-Pain, Lump and Bleeding:1.Prolapsed Haemorrhoids1.Prolapsed Haemorrhoids

-Piles which do not retract and bleed -Piles which do not retract and bleed spontaneously spontaneously

if lump is pushed back into the anal canal.if lump is pushed back into the anal canal.-They may become strangulated, thrombosed -They may become strangulated, thrombosed

or or ulcerated. ulcerated.- They become very painful and tender. - They become very painful and tender.

2.Carcinoma2.Carcinoma-Sq. cell carcinoma of the anal canal is rare.-Sq. cell carcinoma of the anal canal is rare.-It is present with pain on defecation and -It is present with pain on defecation and

streaks of blood streaks of blood on the faeces but also causes on the faeces but also causes palpable lump palpable lump 3.Prolapsed Rectum3.Prolapsed Rectum

3.Prolapsed rectum3.Prolapsed rectumPartial or mucosal prolapse.Partial or mucosal prolapse.Complete prolapseComplete prolapse-Everson of the whole thickness of -Everson of the whole thickness of

the lower the lower part pf the rectum and part pf the rectum and the anal canalthe anal canal

-Occurs when the structures in the -Occurs when the structures in the floor of floor of the pelvis that normally hold the pelvis that normally hold the rectum in the rectum in the curve of the the curve of the sacrum become weak and sacrum become weak and lax. lax.

Ano-Rectal BleedingAno-Rectal Bleeding

Or Bleeding P.R.Or Bleeding P.R.

RECTAL BLEEDINGRECTAL BLEEDING

• Rectal bleeding is a sign that Rectal bleeding is a sign that something is wrong. It is usually something is wrong. It is usually something minor that can be easily something minor that can be easily diagnosed, but not always. diagnosed, but not always.

• Even though rectal bleeding may not Even though rectal bleeding may not be serious, an individual should be serious, an individual should never assume this to be the case. never assume this to be the case. Most importantly, rectal bleeding Most importantly, rectal bleeding may be a sign of rectal cancer. may be a sign of rectal cancer.

Rectal Bleeding

I. Causes II.Diagnosis

I. Causes of Rectal BleedingI. Causes of Rectal Bleeding

1.1. Haemorrhoids. Haemorrhoids.

2.2. Fistula. Fistula.

3.3. Fissure. Fissure.

4.4. Diverticulosis. Diverticulosis.

5.5. Proctitis and Proctitis and Colitis.Colitis.

6.6. Polyps and Cancer Polyps and Cancer ..

7.7. Protrusion of the Protrusion of the Rectum. Rectum.

1. 1. HemorrhoidsHemorrhoids• These are dilated blood These are dilated blood

vessels or veins in the vessels or veins in the anal or rectal area. They anal or rectal area. They can occur on the outside can occur on the outside where they are felt as where they are felt as small bumps when small bumps when wiping. Or they may be wiping. Or they may be on the inside where they on the inside where they are usually painless. They are usually painless. They develop quite commonly develop quite commonly with chronic constipation with chronic constipation and especially with and especially with pregnancy. Hemorrhoids pregnancy. Hemorrhoids are usually treated with are usually treated with stool bulking agents that stool bulking agents that soften the stool and soften the stool and reduce straining. reduce straining.

2. Fistula2. Fistula• A fistula is an abnormal, A fistula is an abnormal,

burrowing channel that burrowing channel that usually runs from the usually runs from the rectum to the skin around rectum to the skin around the anus. It often will drain the anus. It often will drain a whitish discharge, but it a whitish discharge, but it can also bleed. While it is can also bleed. While it is usually just a local usually just a local problem, a fistula can be problem, a fistula can be associated with chronic associated with chronic inflammation in other parts inflammation in other parts of the intestinal tract. This of the intestinal tract. This disorder is called Crohn's disorder is called Crohn's disease. Fistulas are disease. Fistulas are treated with antibiotics and treated with antibiotics and hot baths. If they persist, hot baths. If they persist, surgery is usually required. surgery is usually required.

3. 3. FissureFissure• The passage of a hard The passage of a hard

stool or severe diarrhea stool or severe diarrhea may tear the lining tissue may tear the lining tissue of the anus. This problem of the anus. This problem is similar to having is similar to having cracked lips in cold cracked lips in cold weather. Nerve endings weather. Nerve endings and blood vessels are and blood vessels are exposed so that pain and exposed so that pain and bleeding occur with bleeding occur with bowel movements. bowel movements. Frequent warm baths Frequent warm baths and bulking agents, used and bulking agents, used to keep stools soft, to keep stools soft, usually correct this usually correct this problem. Sometimes problem. Sometimes surgery is needed. surgery is needed.

4. 4. DiverticulosisDiverticulosis• Diverticula are pockets or Diverticula are pockets or

sacs that project from the sacs that project from the bowel wall. They balloon out bowel wall. They balloon out over the years due to over the years due to recurrent, high pressure recurrent, high pressure spasm of the colon. spasm of the colon. Occasionally they can bleed. Occasionally they can bleed. They usually produce a lot They usually produce a lot of blood, and it comes all at of blood, and it comes all at one time. It normally does one time. It normally does not persist in small amounts not persist in small amounts with bowel movements over with bowel movements over days or weeks. Serious, days or weeks. Serious, persistent diverticular persistent diverticular bleeding usually requires bleeding usually requires hospitalization and, at hospitalization and, at times, surgery. times, surgery.

• Either the rectum, colon, or Either the rectum, colon, or both, can become inflamed both, can become inflamed and ulcerated. There are a and ulcerated. There are a number of disorders which number of disorders which cause the inside surface of the cause the inside surface of the bowel to become ulcerated bowel to become ulcerated and bleed. There may be rectal and bleed. There may be rectal urgency, cramps or diarrhea urgency, cramps or diarrhea associated with the bleeding. associated with the bleeding. When the inflammation is When the inflammation is restricted to the rectum, the restricted to the rectum, the condition is called proctitis. condition is called proctitis. When the colon is involved, it When the colon is involved, it is called colitis. It is important is called colitis. It is important to identify the specific cause of to identify the specific cause of the inflammation so that the inflammation so that appropriate treatment can be appropriate treatment can be started. started.

• Of course, the greatest Of course, the greatest concern about rectal bleeding concern about rectal bleeding is cancer. Polyps are benign is cancer. Polyps are benign growths in the colon. When growths in the colon. When polyps reach a large size, they polyps reach a large size, they can bleed. And certain types can bleed. And certain types of polyps turn into cancer. of polyps turn into cancer. Colon cancer is usually Colon cancer is usually curable when discovered curable when discovered early. It most often occurs in early. It most often occurs in people over the age of 50, but people over the age of 50, but it is not unheard of in younger it is not unheard of in younger individuals, even in their 30's individuals, even in their 30's or younger. Because colon or younger. Because colon cancer is such a common cancer is such a common cancer, it is always cancer, it is always considered as a possible considered as a possible diagnosis. diagnosis.

7. Protrusion of the Rectum7. Protrusion of the Rectum

• Some older individuals will have Some older individuals will have weakened rectal support tissues. weakened rectal support tissues. Part of the rectum then can project Part of the rectum then can project from the anus and bleed. This from the anus and bleed. This condition is called rectal prolapse. It condition is called rectal prolapse. It can be felt as an abnormal bulging can be felt as an abnormal bulging from the rectum when wiping. from the rectum when wiping. Surgery is the only effective Surgery is the only effective treatmenttreatment

II. II. Diagnosis.Diagnosis.

1.1. The Medical History.The Medical History.

2.2. The Visual and Digital Exam.The Visual and Digital Exam.

3.3. Endoscopy.Endoscopy.

4.4. Barium Enema X-ray.Barium Enema X-ray.

1. 1. The Medical HistoryThe Medical History

• What is the patient's age? Older people What is the patient's age? Older people tend to have polyps and cancer more often. tend to have polyps and cancer more often. Is there anal pain and a hard, large stool Is there anal pain and a hard, large stool associated with bleeding? A tear of the associated with bleeding? A tear of the anus may be the answer. Does blood drip anus may be the answer. Does blood drip into the toilet after a bowel movement? into the toilet after a bowel movement? Bleeding hemorrhoids may be the problem. Bleeding hemorrhoids may be the problem. The color and frequency of the bleeding The color and frequency of the bleeding are additional considerations. In most are additional considerations. In most cases, the medical history provides clues, cases, the medical history provides clues, but never the final answer. but never the final answer.

2. 2. The Visual and Digital The Visual and Digital ExamExam

• The physician will inspect the anal The physician will inspect the anal area looking for tears and area looking for tears and hemorrhoids. A finger exam can hemorrhoids. A finger exam can provide information when there is provide information when there is tenderness or a tumor inside. In tenderness or a tumor inside. In men, the prostate is also examined. men, the prostate is also examined.

Ano- rectal Ano- rectal ExaminationExamination

Technique for rectal Technique for rectal examinationexamination

A. Preparation:A. Preparation:i. Position of patienti. Position of patient

-Privacy-Privacy-Uncover from nipple to knee-Uncover from nipple to knee-Patient lie in the left lateral side-Patient lie in the left lateral side-Hips flev to 90 or more -Hips flev to 90 or more -Knee flexed less than 90-Knee flexed less than 90

ii. Equipment:ii. Equipment:-Plastic gloves-Plastic gloves-Lubricating jells-Lubricating jells-Good light-Good light-Protoscopy and sigmoidoscopy-Protoscopy and sigmoidoscopy

* Tell the patient what you are doing * Tell the patient what you are doing

B. Examination:B. Examination:i. Inspection:i. Inspection: Lift up the upper buttock from other and Lift up the upper buttock from other and see the anus, perianal skin perineum and see the anus, perianal skin perineum and look forlook for

-Skin rashes-Skin rashes-Faecal soiling, blood or mucus-Faecal soiling, blood or mucus-scars or fistula-scars or fistula-Lumps and bumps-Lumps and bumps-ulcers and specially fissures-ulcers and specially fissures

ii. Palpation: ii. Palpation:

ii. Palpation:ii. Palpation:

-Place pulp pf your right index -Place pulp pf your right index finger on the center of the anus finger on the center of the anus parallel to the skin of the perineumparallel to the skin of the perineum

-Press gently into anal canal -Press gently into anal canal against the skin of the posterior wall against the skin of the posterior wall and pubo-rectalis muscle of the and pubo-rectalis muscle of the canalcanal

-The anal canal :-The anal canal :

note the sphincter tenderness or note the sphincter tenderness or prescience of massesprescience of masses

N.B: If the patient have fissures or N.B: If the patient have fissures or abcesses, don’t try to do rectal abcesses, don’t try to do rectal examination until the patient is examination until the patient is anasthetized anasthetized

The rectum:The rectum:

-Feel the rectum as possible -Feel the rectum as possible

-Note the wall and the prescence of masses -Note the wall and the prescence of masses ulcers ulcers

-Note content of rectum -Note content of rectum

i.e Faeces i.e Faeces

The recto-vesical/ recto-uterine pouch:The recto-vesical/ recto-uterine pouch:

-Turn your finger to detect any masses in -Turn your finger to detect any masses in peritoneal pouch between rectum and peritoneal pouch between rectum and bladder or uterusbladder or uterus

Bimanual ExaminationBimanual Examination

- You can examine the content of the - You can examine the content of the pelvis if your other hand on the pelvis if your other hand on the abdomen and feel bimanually and detect abdomen and feel bimanually and detect the abnormality.the abnormality.

- The cervix and the uterus:- The cervix and the uterus:You can examine these organs by You can examine these organs by bimanual examination.bimanual examination.

- The prostate and seminal vesicles:- The prostate and seminal vesicles:You can feel the benign hypertrophy of You can feel the benign hypertrophy of prostate and carcinoma of prostate.prostate and carcinoma of prostate.

3. 3. EndoscopyEndoscopy• There are several types of endoscopes used There are several types of endoscopes used

to view the colon. In the office, the physician to view the colon. In the office, the physician may use a rigid or, more commonly, a flexible may use a rigid or, more commonly, a flexible viewing sigmoidoscope. This exam is called viewing sigmoidoscope. This exam is called flexible sigmoidoscopy and is performed in 5 flexible sigmoidoscopy and is performed in 5 to 10 minutes. A more thorough exam is to 10 minutes. A more thorough exam is accomplished with a colonoscope, allowing accomplished with a colonoscope, allowing the physician to view the entire 5- to 6-foot the physician to view the entire 5- to 6-foot long colon. Sedation is usually given for this long colon. Sedation is usually given for this exam. Frequently a bleeding lesion will be exam. Frequently a bleeding lesion will be present beyond the reach of the present beyond the reach of the sigmoidoscope. So colonoscopy may be the sigmoidoscope. So colonoscopy may be the best initial exam. Both exams are usually best initial exam. Both exams are usually done on an outpatient basis. done on an outpatient basis.

4. 4. Barium Enema X-rayBarium Enema X-ray

• This is a complementary exam that This is a complementary exam that uses liquid barium inserted by uses liquid barium inserted by enema into the rectum. X-rays enema into the rectum. X-rays highlight abnormal shadows, such as highlight abnormal shadows, such as tumors, diverticuli and colitis. By tumors, diverticuli and colitis. By itself, however, it does not identify itself, however, it does not identify an actual bleeding point. an actual bleeding point.

PilesPiles(Haemorrhoids)(Haemorrhoids)

Definition Definition

• Haemorrhoids are enlarged congested Haemorrhoids are enlarged congested mucosa and submucosa at the level of mucosa and submucosa at the level of the ano rectal junction. the ano rectal junction.

• Types of Haemorrhoids:Types of Haemorrhoids:

-Internal -Internal

-External -External

[Proper name is ‘Peri-anal [Proper name is ‘Peri-anal haematoma]haematoma]

• Causes of HaemorrhoidsCauses of Haemorrhoids

History of HaemorrhoidsHistory of Haemorrhoids

• They occur at all ages but They occur at all ages but uncommon below 20 Years uncommon below 20 Years

• They also occur in children They also occur in children • Patient Should be asked for Patient Should be asked for

– Pain Pain – BleedingBleeding– LumpsLumps– DiscomfortDiscomfort– DischargeDischarge

ExaminationExamination

3

12

9

6

9

12

3

6

Leithotomy Position

Patient lying on left side Scrotu

m

Scrotum

Classification of Classification of HaemorrhoidsHaemorrhoids

• Classification of Classification of haemorrhoids haemorrhoids depends on depends on History:History:– First Degree First Degree – Second DegreeSecond Degree– Third DegreeThird Degree

How Bleeding occurs?How Bleeding occurs?

ComplicationsComplications

Complications present only if piles remain Complications present only if piles remain prolapsed which may:prolapsed which may:

-Ulcerate-Ulcerate

-Bleed-Bleed

-Thrombose-Thrombose

- Strangulate- Strangulate

Diagnosed by inspectionDiagnosed by inspection

Do not try further examination Do not try further examination without anaesthesiawithout anaesthesia

Fistula-in-AnoFistula-in-Ano

DefinitionDefinition

It is a track lined by It is a track lined by epithelium or epithelium or granulation tissue granulation tissue and connects the and connects the lumen of the lumen of the rectum or anal rectum or anal canal with the canal with the external surface.external surface.

CausesCauses

1. Rectal inflammatory disease:1. Rectal inflammatory disease:e.g.e.g. -Crohn's disease -Crohn's disease

-Ulcerative colitis-Ulcerative colitis-Tuberculosis-Tuberculosis

2. Necrosis or infiltration of a tumor:2. Necrosis or infiltration of a tumor:e.g. -Colloid carcinomae.g. -Colloid carcinoma*Fistula-in-ano can run through a *Fistula-in-ano can run through a

variety of anatomical planes.variety of anatomical planes.

HistoryHistory

• Age: all ages.Age: all ages.• Symptoms: Symptoms:

– Discharge: serous or purulent.Discharge: serous or purulent.– Pain: episodic throbbing pain.Pain: episodic throbbing pain.– Surrounding: pruritus aniSurrounding: pruritus ani

• Other symptoms: look for the Other symptoms: look for the symptoms of any other disease that symptoms of any other disease that may have caused the fistula.may have caused the fistula.

ExaminationExamination

-Position:-Position:-Edges:-Edges:-Temperature and Tenderness: -Temperature and Tenderness: -The sinus:-The sinus:-Gentle Pressure:-Gentle Pressure:-There may be scars well:-There may be scars well:-Lymph drainage:-Lymph drainage:-Local tissue:-Local tissue:

Local examinationLocal examination

• Position: 2-4 cm of anal canal and it might be Position: 2-4 cm of anal canal and it might be more than one fistula.more than one fistula.

• Tenderness: the opening is not tender Tenderness: the opening is not tender butbut the the deep tissues is tender and thickdeep tissues is tender and thick

• Rectal examination: Rectal examination: - not painful.- not painful.- 2/3 of the internal openings are found in the - 2/3 of the internal openings are found in the

posterior side and only 1/3 is found in the anterior posterior side and only 1/3 is found in the anterior side.side.

- Palpation of the track is done by 2 fingers. the index - Palpation of the track is done by 2 fingers. the index is in the rectum while the thumb is on perianal skin.is in the rectum while the thumb is on perianal skin.

- Proctoscopy and sigmoidoscopy.- Proctoscopy and sigmoidoscopy.

• Local lymph nodes: Local lymph nodes: – inguinal lymph nodeinguinal lymph node– if there is lymphadenopathy the most if there is lymphadenopathy the most

suspected cause of the fistula is suspected cause of the fistula is lymphogranulomalymphogranuloma

• General examination: General examination:

-NEVER CONFINE YOUR -NEVER CONFINE YOUR EXAMINATION TO THE PATIENT'S EXAMINATION TO THE PATIENT'S PERINEUM.PERINEUM.

Pilonidal SinusPilonidal Sinus

DefinitionDefinition

• The word Pilonidal means The word Pilonidal means a nest of hair.a nest of hair.

• A pilonidal sinus is a sinus A pilonidal sinus is a sinus which contains a tuft of which contains a tuft of hairs.hairs.

• Site: Site:

These sinuses are These sinuses are commonly found in the commonly found in the skin covering the sacrum skin covering the sacrum and coccyx but can occur and coccyx but can occur between the fingers, between the fingers, particularly in particularly in hairdressers and at hairdressers and at umbilicus.umbilicus.

• The hairs in the sinus are The hairs in the sinus are short, broken pieces of short, broken pieces of hair that either get sucked hair that either get sucked into a pre existing dimple into a pre existing dimple in the skin in the or in the skin in the or actually pierce the normal actually pierce the normal skin in the gluteal cleft skin in the gluteal cleft and then by acting as and then by acting as foreign bodies aid and foreign bodies aid and support the development support the development and persistence of chronic and persistence of chronic abcess which flares up at abcess which flares up at frequent intervals into frequent intervals into Acute abcessAcute abcess

HistoryHistory

-Age:-Age:

-Sex:-Sex:

-Ethnic group:-Ethnic group:

-Symptoms:-Symptoms: