benign anorectal conditions ahmed badrek-amoudi frcs

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Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

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Page 1: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Benign Anorectal ConditionsAhmed Badrek-Amoudi FRCS

Page 2: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Anorectal Anatomy

Anal verge

Anal canal

Arterial Supply

Inferior rectal A middle rectal A

Venous drainage

Inferior rectal V middle rectal V

3 hemorrhoidal complexes

L lateral

R antero-lateral

R posterolateral

Lymphatic drainage

Above dentate: Inf. Mesenteric

Below dentate: internal iliac

Nerve Supply

Sympathetic: Superior hypogastric plexus

Parasympathetic :

S234 (nerviergentis

Pudendal Nerve :

Motor and sensory

Page 3: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

HaemorrhoidsBack 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

• R anterior

• R posterior

• But can be found anywhere in anus

• Prevalence is 4%

• Miss labelling by referring physicians and patients is common

This combination is only in 19%

Page 4: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

3 main processes: 1. Increased venous pressure

2. Weakness in supporting fibromuscular stroma

3. Increased internal sphincter tone

Risk Factors

Haemorrhoids

PathogensisAbnormal haemorrhoids are dilated cushions of arteriovenous

plexus with stretched suspesory fibromuscular stroma with prolapsed rectal mucosa

HabitualPathological

1. Constipation and straining

2. Low fibre high fat/spicy diet

3. Prolonged sitting in toilet

4. Pregnancy

5. Aging

6. Obesity

7. Office work

8. Family tendency

1. Chronic diarrhea (IBD)

2. Colon malignancy

3. Portal hypertension

4. Spinal cord injury

5. Rectal surgery

6. Episiotomy

7. Anal intercourse

Page 5: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Haemorrhoids

Classification:

Origin in relation to Dentate lineDegree of prolapse through anus

1. Internal: above DL

2. External: below DL

3. Mixed

•1st: bleed but no prolapse

•2nd: spontaneous reduction

•3rd: manual reduction

•4th: not reducable

Page 6: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Haemorrhoids

Clinical assessment

History ( Full history required)Examination

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

General GI:•Change in bowel habit•Mucus discharge•Tenasmus/ back pain•Weight loss •Anorexia•Other system inquiry

Local•Inspect for:

–Lumps, note colour and reducability–Fissures–Fistulae–Abscess

•Digital:–Masses–Character of blood and mucus

•Perform proctoscopy and sigmoidoscopy

General abdominal examination

Page 7: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

• Lab: CBC / Clotting profile/ Group and save

• Proctography: if rectal prolpse is suspected

• Colonoscopy: if higher colonic or sinister pathology is suspected

Haemorrhoids

Investigations:

The diagnosis of haemorrhoids is based on clinical assessment and proctoscopy

Further investigations should be based on a clinical index of suspicion

Page 8: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Thrombosed internal

haemorrhoids

Thrombosed external

haemorrhoids

Complications

1. Ulceration

2. Thrombosis

3. Sepsis and abscess formation

4. Incontinence

Page 9: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Haemorrhoids

Internal H. Treatment:

Conservative Measures

Grade 1&2• 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

SurgicalIndications:

1. Failed other treatments

2. Severely painful grade 3&4

3. Concurrent other anal conditions

4. Patient preference

Page 10: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

• 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

Haemorrhoids

External H. Treatment:

Page 11: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Perianal Fistula and Abscess

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%

5%

Ischiorectal 20%

Intersphincteric

Trans-sphincteric extrasphincteric

suprasphincteric

Page 12: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Perianal AbscessClinical presentation

AbscessClinical 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

Page 13: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Peri-anal FistulaClinical 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

Page 14: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Aim: adequate drainage of abscess

preservation of sphincter function

* Preop: full lab evaluation

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

Perianal AbscessManagement

AbscessTreatment

Perianal•Incision and drainge de-roof cavity

•pack with gauze and iodine

•IV AB, sitz bath tid, laxitives and anlgesia

•F/U for fistula Ischio-rectal

Intersphincteric

Supralevator

•I&D through interspgincteric plane.

•Treat the underlying cause

Page 15: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Aim: Define anatomy

Eliminate tract

preservation of sphincter function

* Preop: full lab evaluation

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

Perianal fistulaManagment

FistulaTreatment

Perianal•Fistulotomy vs fistulectomy

Trans/Extra/Supra

sphincteric

•Complex treatments using seton

Page 16: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

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

Page 17: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Anal Fissure Clinical Assessment

AcuteChronic

•Sever acute pain

•Fresh blood spotting

•Clean linear tear.

•Pain mild to moderate

•More than 6 weeks

•Hypertrophied Int.sphincter

•Skin tag

•Granulation around the edge

Page 18: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Anal Fissure Treatment

Conservative•High fibre diet•Medical sphincterotomy:

–GTN

–Ca channel blockers

–Butulinum toxins

Surgical

Lateral sphincterotomy

Page 19: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Pilonidal SinusPathogenesis:

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

Page 20: Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Presentation & Treatment

• Also found: umbilicus, finger webs, perianal area

AcuteabscessIncision and drainage

Recurrence: 40%

ChronicPain and discharge

Wide local excision• with primary closure or• closure by secondary intension

Recurrence: 8-15%