Anal Pain and Discharge By: Mohammad Jamjoom - PowerPoint Presentation

1. Anal Pain and DischargeBy: Mohammad JamjoomFahad Al-SabhanSupervised by: Dr. Khayal Al-Khayal

2. Overview:Anatomy of the anal canalHemorrhoidsAnal fissuresAnal abscessesAnal fistulas

3. Anatomy of the anal canal:

4. The anal canal is 4 cm longIt extends from the anal verge to the anorectal junctionIt is divided into upper and lower halves by the dentate (pectinate) lineAbove Columnar epitheliumBelow Squamous epithelium (anoderm)Transitional zone Cuboidal epithelium

5. Internal (involuntary) and external (voluntary) sphinctersThe internal sphincter is a thickened continuation of the circular smooth muscles of the rectum (autonomic nervous system)It is responsible for anal continenceThe external sphincter is a downward extension of the puborectalis muscle (internal pudendal nerve S2-S4)

6. Blood supply:Arterial supply:Upper half Superior rectal arteryLower half Inferior rectal arteryVenous drainage:Upper half Superior rectal vein Portal systemLower half Inferior rectal vein Systemic circulation

7. Hemorrhoids:They are engorgement of the venous plexi of the rectum, anus or both; with protrusion of the mucosa, anal margin or bothAlso known as “Piles”

8. Types:Internal hemorrhoidsExternal hemorrhoidsAbove the dentate lineBelow the dentate lineCovered with mucosaCovered with anodermPainlessPainful & itchyMay bleed or prolapseDo not bleed, may thrombose

9. Sites:Left lateral (3 o’clock)Right posterior (7 o’clock)Right anterior (11 o’clock)

10. Classification of internal hemorrhoids:1st degree: Do not prolapse2nd degree: Prolapse with straining, but are reduced spontaneously3rd degree: Prolapse with straining, but require manual reduction4th degree: Cannot be reduced

11. Etiology:Constipation or strainingIncreased abdominal pressurePregnancyPortal hypertension

12. Signs and symptomsAnal mass or prolapseBleedingPruritisPain or discomfortSensation of fullnessMucoid discharge and soiling of underwear

13. Diagnosis:HistoryRectal examinationProctoscopySigmoidoscopy or colonoscopy

14. DDx:Anal polypsAnal fissuresPeri-anal hematomaRectal prolapseIBDDermatitisAnorectal carcinoma

15. Management:Nonoperative (90%):High fiber diet Increase fluid intakeLaxativesAvoid straining during defecationAnal hygieneTopical steroidsSitz bath

16. Surgical (10%):1st degree:SclerotherapyInfra-red photocoagulationLiquid nitrogen cryotherapy2nd degree:Rubber band ligation3rd and 4th degree:Excisional hemorrhoidectomy

17. Contraindications to surgery: AnticoagulantsPortal hypertension and liver cirrhosis class CCrohn's diseaseAnorectal fissures Anorectal infectionsAnorectal tumorsPregnancyRectal wall mucosal prolapse

18. Complications:Exsanguination (bleeding may pool proximally in lumen of colon)Pelvic infection (sepsis)Urinary retentionIncontinence (sphincter injury)Anal strictureAbscess

19. Anal Fissures:They are tears in squamous epithelium of the anus (anoderm)Most common cause of anal painMost common site is the posterior midline

20. Etiology:Hard stool or constipationHyperactive sphincterDisease process (Crohn’s disease)

21. Signs and symptoms:Tearing pain with defecationRectal bleeding (blood streaks on toilet paper)Painful rectal examinationSentinel pile (tag)Hypertrophic papilla

22. Diagnosis:HistoryRectal examinationProctoscopy

23. Management:Nonoperative (80%):High fiber diet Increase fluid intakeLaxativesAvoid straining during defecationAnal hygieneTopical nifedipineSitz bathBotox

24. Surgical (20%):Chronic fissures refractory to conservative treatmentLateral internal sphincterotomy (LIS)

25. Anal Abscesses and FistulasThey may present as acute or chronic manifestations of the same perirectal disease

26. Anal Abscess:It’s an infection of the soft tissues surrounding the anal canal, with formation of a discrete abscess cavity

27. Classification of anal abscesses:Perianal (60%)Ischiorectal (20%) Intersphincteric (5%)Supralevator (pelvirectal) (4%) (is very difficult to diagnose clinically and is very rare and caused by inflammation or a disease in the pelvis)Submucosal (1%)

28. Etiology:Blockage of anal glands which permits the growth of bacteria leading to an abscess formationCommon organisms: - Escherichia coli  - Enterococcus species - Bacteroides speciesHowever, no specific bacterium has been identified as a unique cause of abscessesLess common causes: Tuberculosis, squamous cell carcinoma, adenocarcinoma, actinomycosis, lymphogranuloma venereum, Crohn's disease, trauma, leukemia and lymphoma

29. Note:most people have 8 to 10 glands , which are located circumferentially within the anal canal at the level of the dentate line, penetrate through the internal sphincter and end in the intersphincteric plane

30. Signs and symptoms:Severe pain in the anal area (pain is constant and not necessarily associated with bowel movements)Lump in the anal areaLower abdominal pain (pelvirectal abscess)Constitutional symptoms ( fever, malaise) Drainage of pus

31. Management:Early incision and surgical drainage of the purulent collectionSitz bathAnal hygiene LaxativesThere is no role for antibiotics except for patients who are:- Immunocompromised- Diabetics- Diagnosed with valvular heart diseases- Diagnosed with cellulitis

32. Complications:A potential complication of anorectal abscess drainage is the formation of fistulous tracts within 6 months in 50% of cases

33. Anal Fistulas:They are abnormal connections between the epithelialized surface of the anal canal and the perianal skin

34. Classification of anal fistulas:The 4 categories of fistulas according to Park’s classification, based on the relationship of fistula to sphincter muscles, are:IntersphinctericTransphincteric (most common)Supra-sphinctericExtra-sphincteric.

35. Etiology:Opened perianal or ischiorectal abscesses, which drain spontaneously through these fistulous tractsFistulas can be found in patients with Inflammatory Bowel Disease (Crohn’s disease)Diverticulitis, foreign body reactions, actinomycosis, chlamydia, lymphogranuloma venereum, syphilis, tuberculosis, radiation exposure and HIV

36. Signs and symptoms:Recurrent malodorous perianal drainagePruritusRecurrent abscessesFever Perianal pain due to an occluded tract, may have pain during defecation

37. Physical examination:Digital examination is usually all that is required, assessment of the anatomy of an anal fistula is very importantDigital examination in a patient with a fistula-in-ano may reveal an indurated tract or cordFistula can be identified by small circles of granulation tissue, which exudes pus when compressed if tissue is patentA fistulous tract that opens internally can be visualized with aid of an anoscopeInguinal lymph nodes may be enlarged and painfulIn an acute fistulous abscess, cardinal signs of inflammation, (erythema, pain, increased temperature, edema) may be found

38. What to asses during physical examination:Often done in the ORExternal openingInternal opening (Internal opening could be identified during fistula surgery, where we inject hydrogen peroxide (H2O2) & look for internal bubbling or inject methylene blue dye)Course of the tractAmount of sphincter muscle involved

39. Investigations:CBC (number of WBC in significant infection), blood culture Fistulogram Transanal USMRI CT

40. Goodsall’s rule:One of the most common used principles to assist in surgical management of fistulasFistulas originating anterior to a transverse line through the anus will course straight ahead and exit anteriorlyWhereas, fistulas exiting posteriorly have a curved tract

41. Management:There are several stages to treating an anal fistulaDefinitive treatment of a fistula aims to stop it from recurringTreatment depends on where the fistula lies and which parts of the anal sphincter it crosses

42. Cutting setonDraining setonFistulotomyFistula plugAdvancement flap

43. Cutting seton:Is a thick suture placed through the fistula tract and staged pulling is done, so it will allow fibrosis and maintain continenceDraining seton:A length of suture material looped through the fistula which keeps it open and allows pus to drain outIt only relieves symptoms, and can be used in patients with Crohn’s disease

44. Fistulotomy:A surgical opening of a fistulous tractFistula plug:Involves plugging the fistula with a device made from small intestinal submucosa

45. Advancement flap:The internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the internal opening was, the flap is pulled down over the sewn internal opening and sutured in place

46. Intersphincteric fistulae: Primary fistulotomyLow Transsphincteric fistulae: Primary fistulotomyHigh transsphincteric or anterior fistulae: In female patients should be treated with a more conservative approach, for example a cutting seton or a fistula plug as to avoid fistulotomy incontinenceSuprasphincteric fistulae: Advancement flaps, sphincter reconstruction or cutting setons. Fistulotomy should not be performed, to avoid incontinenceExtrasphincteric fistulae: Endorectal advancement flap

47. Contraindications of fistulotomy:Anterior fistulas in females (perform a seton to avoid injuring the perineal body, due to it’s proximity)A high level fistulaPatients diagnosed with Crohn’s disease

48. Thank you…