PERIANAL CONDITIONS Raad Dowais, MD - PowerPoint Presentation

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PERIANALCONDITIONS

Raad Dowais, MD

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Anatomy of the Anal Canal

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Below

dentate line

Above

dentate line

Embryological origin

Ectodermal

origin

Similar to the nearby

skin with some

differences.

From the Hindgut

Similar to the Rectum

& the rest of the GIT.

Epithelium

Stratified

Squamous

Epithelium ,BUT it is

modified , it lacks hair

follicles & lacks sweat

glands.

Columnar Epithelium

(single layer)

Innervation

Somatic type of

innervation

, so it is so

sensitive to pain, touch

& temperature.

Autonomic type of

innervations, so –as the

remaining of the GIT- it

is sensitive to

distension

and ischemia.

Lymphatic Drainage

Inguinal LNs

Mesenteric & Para-

aortic LNs

Blood supply

Systemic circulation

Pudendal

artery

 inferior rectal

artery

Portal

circulationInferior

Mesenteric

Artery

 superior

rectal artery

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Hemorrhoids

Hemorrhoids are part of the normal structure of the anal canal.

Anatomically the three main cushions are located

in:

The left lateral

R

ight anterior

Right

posterior positions

.

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Each of these thicker layers has a

submucosa

filled with blood

vessels and

muscle

fibers.

muscle fibers are thought to be important in maintaining

the integrity

of the

hemorrhoid.

The arterial blood supply to hemorrhoids is

primarily from the terminal branches of the superior

hemorrhoidal

artery

; branches of the middle

hemorrhoidal

artery also

contribute

.

Venous outflow

is from the superior, middle,

and inferior

hemorrhoidal

veins.

Slide6

Pathophysiology: The

submucosa

of the anal canal has a rich blood supply with a cavernous and capillary network of blood vessels covered by a thin epithelium ,These highly vascular cushions can become congested, enlarge, bleed and

prolapse

.

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Causes:Excessive straining

Chronic constipation

L

ow-fiber diet

C

arcinoma of the rectum

P

regnancy

Portal

hypertension

(rare

cause)

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Hemorrhoid symptoms

Bright

red blood in stool

– Dripping in toilet

– On wiping after

defecation

Anal itching

Feeling of

prolapsing mass through the anus (

during defecation,

walking,

or straining)

If complicated by

Thromosis

of external hemorrhoids: sharp pain

I

n

case of

strangulation: severe pain, systemic illness

Bright red bleeding and prolapse are

the most common symptoms associated with hemorrhoids.

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Classification

According to site:

classified

as

internal, external,

or mixed

.

Internal

hemorrhoids :

are those

originating

above

the dentate line

.

external

hemorrhoids :

originating below

the

dentate line

.

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Classification of hemorrhoids by degrees :

1st stage

:

no prolapse

outside the anal verge. Only inside the anal canal.

2nd stage

:

prolapse that

reduces spontaneously after defecation.

3rd stage :

prolapse that

the patient has to reduce it manually.

4th stage:

irreducible

prolapse

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*When we describe hemorrhoids we assume that the patient is in the lithotomy position ( delivery position ) and we look at the anal canal as a clock , and we use the clock numbers in descriptions :

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hemorrhoids are classically present at 3 classical sites ( 3, 7 , 11) (( in the right picture above ; 3 o’clock = left lateral cushion ; 7 o’clock = right posterior cushion ; 11 o’clock = right anterior cushion )) .... WHY ?

because that’s the blood supply of the anal canal ( positions of the main vessels) , two vessels at the right & one vessel on the left side.

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COMPLICATIONS

1)

Thrombosed

hemorrhoids:

Clinical

presentaions

:

Severe sharp pain in the first 48

hours.

Physical examination:

Tender tense blue subcutaneous

swelling at anal margin covered by smooth shinny skin.

Management:

Most cases resolve spontaneously within 2 weeks with conservative therapy. Some cases may require incision and removal of clot

2) Ulceration

3) Strangulation

4)Anemia:

Rarely, chronic blood loss from hemorrhoids may cause anemia

“Especially internal hemorrhoids “

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ManagementTreatment aggressiveness is determined by the degree

of symptoms

.

Treatment

of hemorrhoids can be categorized

into:

-Medical management

-Office-based treatments

-Operative therapies

.

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Medical Management

Dietary

:

consist of a high-fiber

diet accompanied

by an adequate fluid

intake. (

It

can take

up to 6 weeks for the fiber therapy to show

benefit).

Stool

softeners

(

Hyperosmolar

laxatives such as

polyethylene glycol

are a good choice

)

Sitz

baths

are often used as part of the treatment for hemorrhoids. They are designed to decrease pain, burning, and itching following a bowel

movement

, and to relax the anal sphincters to improve venous return from the hemorrhoidal cushions

Topical

Therapies

:

topical

ointments containing steroids (anti-inflammatory) and local anesthetic

Oral

Therapy

:

Flavonoids

,

hesperidin

(

daflon

)

Slide19

Office-based treatments(non-surgical methods)

if the conservative treatment

fails, or for stage II internal hemorrhoids

:

-

Sclerotherapy

:

injection of hemorrhoid with

sclerosing

material.

-

Infrared

Photocoagulation

(

Energy ablation can be used to treat internal

hemorrhoids)

-Cryosurgery ( cold nitrogen).

-Rubber band ligation

:

to

ligate

around the neck

of the internal hemorrhoid

to strangulate it.

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Operative Management of Hemorrhoids

usually

reserved for

those patients who have failed medical management

or have

recurrent, persistent

symptoms

.

Usually for stage III-IV hemorrhoids

Typically, only 5–10% of patients with

hemorrhoidal

complaints require operative

hemorrhoidectomy

.

Excisional

Hemorrhoidectomy

-Closed

Technique

Excisional

Hemorrhoidectomy

Open

Technique

Stapled hemorrhoidopexy

Mucosuspension

Transanal hemorrhoidal artery ligation (THD)

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Anal FissureAn anal fissure is a tear in the epithelial lining of the distal anal canal.

The

fissure causes usually

severe

sharp pain

because this area is supplied

by somatic

nerves so it is sensitive to touch, pain and temperature just like the skin.

Slide26

The cause:

a vicious circle of (pain - spasm of internal sphincter - constipation) with unknown starting

point

Constipation



passing hard

stool



mucosal tear



painful

defacation

 spasm of the internal sphincter  avoiding defecation because it is painful  stool stays long time in the sigmoid and rectum  more absorption of water from the stool  hard stool  constipation  ….

Slide27

-Fissures can be classified

as:

Acute VS. Chronic

Typical VS. Atypical

Acute fissures

symptoms

<6 weeks

chronic fissures

symptoms

beyond 6–8 weeks.

Typical fissures

located in the

posterior midline (90%)

or

anterior midline (10%),

and are not associated with other diseases

atypical fissures can occur anywhere in the anal

canal.

and

tend to be associated with other

diseases (

Crohn’s

disease, HIV, TB, malignancy, Syphilis…)

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The best way to differentiate between the acute and chronic anal fissure is the signs of chronicity(triad) which are:

1- deep with a lot of fibrosis

2- reactionary polyps at the proximal end of the fissure (hypertrophied anal papilla)

3- Sentinel piles or skin tags: a skin reaction trying to cover, protect and heal the fissure), this can be seen at the distal end of the fissure.

Slide30

Clinical features Common in middle aged women, not in elderly

.

Pain

is severe in nature in acute

type(

cause bright red bleeding

with bowel

movements and sharp, burning, tearing anal

pain),

whereas less severe

in chronic.

Constipation, bleeding and discharge

.

In

chronic fissure, ulcer is felt with button like depression,

induration

and often sentinel pile.

Slide31

Management

-

Nonoperative

Treatment:

-

Topical:

Nitroglycerin ,

Calcium Channel

Blockers,

Botulinum

Toxin Type

A.

-

Operative Treatment:

-

Anal

Dilation under GA

-

Partial lateral internal

s

phincterotomy

-

Fissurectomy

* treat the constipation(

diet,laxatives

) , relieve the pain (local analgesics

sitz

baths )

Slide32

Anorectal abscess

It is a collection of pus in the anal/rectal region.

-

Most common causative organism is

E. coli (60%).

Others are

Staphylococcus,

Bacteroides

, Streptococcus, B.

proteus

-95% of

anorectal

abscesses are due to infection of

anal glands in relation to crypts—

cryptoglandular

disease.

.

*How does the problem start?

-the most acceptable theory is

(crypto-glandular theory)

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(crypto-glandular theory):

Slide34

Other causes: Injury to anorectum

.

Cutaneous

infection (e.g. Boil).

Blood born infections

.

Perianal

haematoma

.

Post-

anorectal

surgery.

Crohn‘s

disease.

Tuberculosis.

Slide35

Classification™

Perianal

intersphincteric

™

Ischiorectal

™

Submucous

™

Pelvirectal

™

Fissure abscess

(in relation to fissure-in-

ano

).

Slide36

If the abscess remains

in the

intersphincteric

space

,

then the patient will present with

intersphincteric

abscess.

If the pus goes down, the collection will be at the anal verge and the patient will present with a bulge in the

perianal

skin

(

perianal

abscess).

If the pus goes up above the

levator

ani

muscle

(supra

levator

abscess)

If the pus can pass through the external sphincter to the

ischiorectal

space

(

ischiorectal

abscess)

the pus can leak through

the post-anal space

and go around the anal canal

(

horse-shoe

abscess).

Slide37

Presentation:

( like any abscess anywhere=> septic picture

)

1- throbbing pain

2- fever and toxicity

3- patient is unable to set

*Physical findings:

(depend on the type of the abscess):

1- in

perianal

abscess the

perianal

skin is red, tender and swollen

(more common If the abscess near to the skin)

2- in

supralevator

abscess deep pain with little or no outside physical findings

3- in

intersphincteric

abscess if you do PR examination you'll find a mass and tenderness.

4- in

ischiorectal

abscess it depends on the site:

-in high level

little

or no external findings

- in low level

red tender and swollen skin

Slide38

Investigations

-

MRI

is the

investigation

of

choice

for

anorectal

abscess.

Perineal

and anal US

is also very useful.

-

Proctosigmoidoscopy

is needed to identify secondary cause in

anorectum

.

Slide39

complicationRecurrent

abscess

formation

™

Fistula

formation

Slide40

Management:

Incision and Drainage

(Once you decide to drain the abscess, you have to warn your patient

that there is a chance around 50% of recurrence and 50% of fistula formation.)

Role of Antibiotics:

Antibiotic s are indicated when associated

cellulitis

is present, in patients who

fail to improve

following appropriate drainage, and those with

immunosuppressed

states (diabetes, Leukemia, AIDS; or Those who are undergoing chemotherapy

Slide41

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Fistula-in-ano can be:

- Cryptoglandular—90%.

- Non-

cryptoglandular

(other causes)—10%.

Other causes are (Non-

cryptoglandular

)

™ Tuberculosis

™ Carcinoma

™

Crohn’s

disease

™ Ulcerative colitis

™

Lymphogranuloma

venereum

™

Hydradenitis

suppurativa

™ Traumatic

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Diagnosis

The symptoms of an

anorectal

fistula will be quite

variable based

on the location of the external opening, the

complexity of

the tract, the patient’s

tolerance.

Bleeding, pain,

Severe

pain

(should

be a red

flag for another etiology of the fistula such as malignancy

or

Crohn’s

disease) ,

If a patient has

gastrointestinal symptoms

such as

abdominal cramping, bloating, early satiety, or weight loss

an associated diagnosis such as IBD

or malignancy

must be excluded.

Slide47

Investigations

-

MRI/MRI

fistulogram

ideal.

-

Endorectal

ultrasound (US perineum) is useful to assess deeper plane.

- Colonoscopy often when ulcerative colitis/

Crohn’s

is suspected.

Slide48

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Treatment

The goals of treatment:

Elimination of sepsis.

2. Closure of the fistula track.

Preservation of patient’s fecal continence and sphincter function.

Minimizing recurrence.

Slide50

Lay Open Technique (Fistulotomy)

Setons

:

used to treat anal fistula when a lay

open

technique is not possible or not advisable.

Ligation of

Intersphincteric

Fistula

Fibrin

Glue

Anal Fistula

Plug

Injection of endogenous adipose tissue

Slide51

Anal cancer

Anal cancer accounts for only a small percentage (4 %) of all cancers of the lower alimentary tract.

Risk factors associated with anal cancer:

• Sexually transmitted disease.

• Anal receptive intercourse.

• More than ten sexual partners.

• The presence of precancerous anal lesions such as

condylomas

or high-grade anal intraepithelial

neoplasia

, and

cervical,

vulvar

, or vaginal cancers.

•

Immunosuppression

secondary to solid organ transplantation or chronic

glucocorticoid

therapy.

• HIV

seropositivity

, low CD4 count.

• Smoking.

Slide52

Classification of tumours of anal area

™

Benign

or malignant

™

Tumors of

the anal canal (proximal to dentate line)—SCC,

adenocarcinoma

, melanoma

™ Anal margin

tumor

(distal to dentate line

):

Bowen’s

disease, Paget’s

disease, BCC, anal margin

SCC

Slide53

Types

1.

Squamous

cell carcinoma

is the commonest type.

Predisposing causes:

Papilloma

, irradiation, dermatitis, long standing fistula-in-

ano

.

2.

Basaloid

carcinoma—it is rare, non-

keratinising

squamous

cell carcinoma. Highly malignant.

3.

Muco-epidermoid

carcinoma—arises near

squamo

–

columnar junction.

4. Basal cell carcinoma.

5. Melanoma—blue/black in

colour

mistaken for

thrombosed

pile—poor prognosis (5 years—10%).

6.

Adenocarcinoma

from the anal glands in a pre-existing

fistula-in-

ano

.

Slide54

Features

Ulceration

Bleeding

Pain,

pruritus

and discharge

Irregular

indurated

mass

Anovaginal

fistula in females

Fecal

incontinence in late cases.

Inguinal node—hard, non-tender

Iliac nodes

Later—late constipation—obstruction

Slide55

Investigations

• Biopsy from anal region

• FNAC of inguinal node

• US abdomen

• MRI perineum is very useful

• P/R is a must to assess upper

extent of the growth

Slide56

Management

Slide57

ChemoradiationDrugs used for chemotherapy are 5 FU, bleomycin

,

vincristine,adriamycin

.

If persistent or recurring disease presents following combined modality therapy (CMT—

chemoradiotherapy

), APR with colostomy is indicated.

Neoadjuvant

chemotherapy using

5 FU,

cisplatin

and

mitomycin

C

is also commonly used.

In advanced growths radiotherapy is the only treatment.

All other

tumours

:

Abdominoperineal

resection with

permanent

colostomy is done.

Slide58

CONDYLOMA ACUMINATA

- It is most common sexually transmitted anal disease. It is

common in homosexual men.

- Penile warts or female genital warts may be present.

- It is caused by Human

Papilloma

Virus (HPV).

-

Pruritus

, discharge, pain and bleeding are the features.

- Large wart may block the anal canal orifice.

- Whitening occurs on applying acetic acid on it.

- Biopsy confirms the diagnosis.

- Treatment is local application of 25%

podophyllin

cream;

surgical excision of the wart;

intralesional

injection of

interferon a 2b.

- Malignancy should be ruled out by histology.

Slide59

HPVHerpes infection.- Sexually transmitted disease.(STD)

- Very painful.

- In early stage we can treat it with antiviral drugs, but in late stage we

have to wait for the disease to limit by itself.

Slide60

Warts:-caused mainly by HPVHPV16,18 is associated with high risk of cervical cancer (50% of the cases) while HPV6

and HPV11 have low risk of cancer and they are more common.

-we have the problem of recurrence and 20% of the patient will have another STD.

Slide61

-presentation: itching, bleeding, headache, discharge, urethral obstruction-treatment: we start with medical treatment if it fails, we remove them by

laser, cryosurgery,

electrocautery

, if it fails we go to the classical surgery

.

keep in mind that it's important to take care of the partner also.

Slide62

RECTAL PROLAPSE

It is

circumferential descent

of rectum (bowel) through the anal canal.

It is commonly seen in

elderly females

.

Much more common in females

-

Fecal

incontinence

is very common feature; urinary incontinence occurs in 35% of patients; 15% of patients are associated with vaginal vault prolapse

Slide63

Etiology

Obstetric injury (the commonest cause)

Chronic

constipation with

straining

Collagen diseases

Slide64

Rectal prolapse can be:

Partial.

Complete.

Hidden/concealed

:

It is internal

intussusception

of the sigmoid into the rectum or part of the rectum distally; they do not come out of the anal orifice

.

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Complications of rectal prolapse

-™ Ulceration, bleeding,

anaemia

™

-

Proctitis

, sepsis

-™ Irreducibility, gangrene

Rupture

with

evisceration

Anal

inconitence

Slide67

Investigations

Anal

manometry

Anal ultrasound

MR-

defecography

Slide68

Treatment for complete prolapse

Ventral

sacro

-rectopexy

Delorme’s operation

Altemeier’s

operation