3rd degree hemorrhoids

4th degree hemorrhoids

Open hemorrhoidectomy

Closed hemorrhoidectomy

Stapled Hemorrhoidectomy

Instructions following anorectal operations

• Diets

• Sitz baths

• Dressings

• Medications:

Bulk-forming agents

Anagesics; NSAIDS, Paracetamol

Antibiotics; Metronidazole, Augmentin

Anal Fissure

Pathology

• It is a tear or crack in the lower portion of the anal canal

• It may be acute or chronic

• Causes:

1- Passage of large,

hard stool .

2- Explosive diarrhea.

3-Trauma to the anus.

Anal Fissure (cont.)

-100% men posterior midline.

-10% women anterior midline.Patients tend to have high internal

sphincter tone with resulting poor

anodermal perfusion to the posterior

portion .

Anal Fissure (cont.)

History1- Pain during and after bowel motion.

2- Streaks of blood on stools or tissue paper.

AR examination:

-High anal sphincter tone.

- Just separating the skin around anus will display the fissure.

- Associated findings

• – sentinel tag externally

• – enlarged anal papilla internally

(No attempts to do P.R. during acute stage)

Anal Fissure (cont.)

acute chronic

Treatment of Anal Fissure

Anal Fissure (cont.)

Anal Fissure

Acute Chronic

Non-surgical

ResolutionLateral

Internal

Sphincterotomy

Failure

Repeat Rx

Resolution Treat as chronic

Rule out

other causes

Resolution Failure

Repeat Sphincterotomy

Vicious cycle of anal fissure

Treatment of Anal Fissure (cont.)

• Non-surgical• Dietary: high fiber, avoid spicy foods

• Local anaesthetic : 10% Xylocaine jelly

• Local hydrocortisone: proctosedyl ointment

• Local Nitrates (e.g. Glyceryl trinitrate)

• Calcium channel blockers (e.g.nifedipine, diltiazem)

• Botulinum toxin

Cochrane database of systemic reviews. 2004, Vol2

OPEN:Internal sphincter directly visualized

CLOSED:Blade no.11 stabin between the int. and ext. anal sphincter

Surgical

Anorectal Abscess/fistula

• Pathogenesis : mostly 2° to

nonspecific anal gland infection

• infection → intersphincteric abscess

• – Abscess represents acute infection

• – Fistula -chronic sequelae of anorectal abscess

•Intersphincteric

(#3)•Extending up ordown• can becircumferentialSupralevator

Ischiorectal#2

Perianal #1

Pathogenesis

Classification of Anorectal Abscesses

Clinical Presentations of Anorectal Abscess

• Pain & swelling (~95%)

• Discharge (only 15%)

• Fever (only 18%)

• M:F ~2:1

• Peak incidence 20-40 y/o

• PE: Bimanual palpation

Anorectal Abscess:Differential Diagnosis

Bartholin’s glandAbscess

InfectedPilonidal sinus

Hidradenitis

Anorectal Abscess:Treatment

• Anoscopy (look for internal opening)

• Incision & Drainage: mostly under LA

• Postop: sitz baths, dressing changes, pain control, antibiotics?

Anorectal Abscess (cont.)

• If PR finds internal bulge → internal

• sphincterotomy over abscess

• • Special situations:

• – Supralevator: drained via rectum

• – Horseshoe abscess: drained via rectum with counter drains in ischiorectal space

Horseshoe Abscess

Fistula-in-ano

• Pathogenesis• Chronic form of anorectal abscess

• Communication between the internal opening at the dentate line and the external opening at the perinealskin

• usually within 3 months following of anorectalabscess

• Incidence : 40-60% of anorectal abscess

Goodsall’s Rule

• Prediction of the tract

• between 2 openings

• • Anterior → straight

• • Posterior → curved

Classifications ofFistula-in-ano

IntersphinctericMost commonTract confined toIS plane

Transsphincteric:Goes through bothsphincters

SuprasphinctericTract loops oversphincters, goesthrough levator

ExtrasphinctericRectum to skinWith or without involvingsphincters

Fistula-in-ano

• Evaluation

• Anoscopy + gentle probe of tract

• Goodsall’s rule to anticipate fistulous tract

May use methylene blue/H2O2

• Flexible sigmoidoscopy,Fistulography,ERUS and MRI may help in complicated cases

Fistula-in-anoevaluation

Fistula-in-anoevaluation

Fistula-in-anoevaluation

Fistula-in-ano

• Treatment• Aim• healed vs. incontinence

• • Incise skin, see how much sphincter involved• – small →fistulotomy, fistulectomy• – a lot → seton (staged procedure) vs. advancement flap

Fistulectomy

WHICH DISEASE ??

MASS BLEEDING PAIN DISCHARGE

EXT.HEMORRHOIDS

++++ +/- +++ +/-

INT.HEMORRHOIDS +++ ++++ +/- +

ANAL FISSURE + + ++ ++++ +/-

ANORECTAL

ABSCESS +++ +/- ++++ +

FISTULA-IN-ANO +++ + ++ ++++

Take Home Messages

• All anal complaint is not due to hemorrhoids

• Take history of mass,bleeding,pain and discharge

• Complete anorectal examination should be part of the evaluation

• Think biopsy for ulceration or skin changes

• Fiber is the colon’s best friend

Thank YouFor

Your Attention