ANORECTAL DISEASES

Bernard M. Jaffe, MDProfessor of Surgery, Emeritus

Tulane University School of Medicine

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

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

ANAL SKIN• Continuous with Anal Canal• Contains Apocrine Glands• Site of Hydradenitis Suppurativa• Pain Receptors (Not Stretch)• Lesions Drain to Inguinal Nodes

VASCULAR• Arterial Supply• Bilateral, Duplicated• Middle and Inferior Hemorrhoidal

Arteries Off Internal Iliac• Venous Drainage• Bilateral, Duplicated• Internal Iliac Veins to Inferior Vena

Cava

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

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

EXTERNAL HEMORRHOIDS• Covered by Anoderm• Distal to Dentate Line• Swell, Causing Discomfort, Difficult

Hygiene• Sever Pain Only with Thrombosis

INTERNAL HEMORROIDS• Cause Painless Bright Red Bleeding• Prolapse with Defecation• Mucus Secretion• Itching • Pain is Rare (No Mucosal

Pain Receptors)

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

OFFICE TREATMENT• Dietary Management (for All Grades)• Fiber Supplements• Local Hygiene• Avoidance of Straining• Medication to Soften Stool• More Extensive- Rubber Band

Ligation

HEMORRHOIDECTOMY• Indications• Failure of Conservative Measures• Prolapse Requiring Manual Reduction• Strangulation• Ulceration• Commonest Complications• Bleeding• Urinary Retention

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

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

OTHER SITES OF ABCESS• Intermuscular- Vertical Tracking• Supralevator- Vertical Tracking• Tough to Diagnose• Ischiorectal- Horizontal Tracking• Horseshoe- Circumferential Tracking

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

OPERATIVE DRAINAGE• OR Required for • Complex (Horeshoe Abcess)• High (Supralevator) Abcess• Immunocompromised

Patients• Patients With Systemic

Symptoms

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

TYPES OF FISTULAS• Type 1- Intersphincteric• Treated by Fistulotomy• Type 2- Transsphincteric• Type 3- Supersphincteric• Type 4- Extrasphincteric• Latter 3 Treated With Seton

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

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

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

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

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

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

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

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

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•

TREATMENT• Superficial Lesions <2cm- Local Excision• Remainder- Nigro Protocol (Radiation, 5-FU,

Mitomycin)• Almost All Respond and

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