Anal Pain and Discharge

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Anal Pain and Discharge




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Presentations text content in Anal Pain and Discharge

Slide1

Anal Pain and Discharge

By: Mohammad Jamjoom

Fahad

Al-

Sabhan

Supervised by: Dr.

Khayal

Al-

Khayal

Slide2

Overview:

Anatomy of the anal canal

Hemorrhoids

Anal fissures

Anal abscesses

Anal fistulas

Slide3

Anatomy of the anal canal:

Slide4

The anal canal is 4 cm long

It 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

Slide5

Internal (involuntary) and external (voluntary) sphincters

The internal sphincter is a thickened continuation of the circular smooth muscles of the rectum (autonomic nervous system)

It is responsible for anal continence

The external sphincter is a downward extension of the

puborectalis

muscle (internal

pudendal

nerve S2-S4)

Slide6

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

Slide7

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”

Slide8

Types:

Internal

hemorrhoids

External hemorrhoids

Above the dentate line

Below the dentate line

Covered with mucosa

Covered with

anoderm

Painless

Painful & itchy

May bleed

or

prolapse

Do not

bleed, may

thrombose

Slide9

Sites:

Left lateral (3 o’clock)Right posterior (7 o’clock)Right anterior (11 o’clock)

Slide10

Classification of internal hemorrhoids:

1

st

degree

:

Do not

prolapse

2

nd

degree

:

Prolapse

with straining, but are reduced spontaneously

3

rd

degree

:

Prolapse

with straining, but require manual reduction

4

th

degree

:

Cannot be reduced

Slide11

Etiology:

Constipation or straining

Increased abdominal pressure

Pregnancy

Portal hypertension

Slide12

Signs and symptoms

Anal mass or

prolapse

Bleeding

Pruritis

Pain or discomfort

Sensation of fullness

Mucoid

discharge and soiling of underwear

Slide13

Diagnosis:

History

Rectal examination

Proctoscopy

Sigmoidoscopy

or colonoscopy

Slide14

DDx:

Anal polyps

Anal fissures

Peri

-anal hematoma

Rectal

prolapse

IBD

Dermatitis

Anorectal

carcinoma

Slide15

Management:

Nonoperative

(90%)

:

High fiber diet

Increase fluid intake

Laxatives

Avoid straining during defecation

Anal hygiene

Topical steroids

Sitz

bath

Slide16

Surgical (10%)

:

1

st

degree

:

Sclerotherapy

Infra-red photocoagulation

Liquid nitrogen

cryotherapy

2

nd

degree

:

Rubber band ligation

3

rd

and 4

th

degree

:

Excisional

hemorrhoidectomy

Slide17

Contraindications to surgery:

Anticoagulants

Portal hypertension and liver cirrhosis class C

Crohn's

disease

Anorectal

fissures

Anorectal

infections

Anorectal

tumors

Pregnancy

Rectal wall mucosal

prolapse

Slide18

Complications:

Exsanguination

(bleeding may pool proximally in lumen of colon)

Pelvic infection (sepsis)

Urinary retention

Incontinence (sphincter injury)

Anal stricture

Abscess

Slide19

Anal Fissures:

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

Slide20

Etiology:

Hard stool or constipation

Hyperactive sphincter

Disease process (

Crohn’s

disease)

Slide21

Signs and symptoms:

Tearing pain with defecationRectal bleeding (blood streaks on toilet paper)Painful rectal examinationSentinel pile (tag)Hypertrophic papilla

Slide22

Diagnosis:

History

Rectal examination

Proctoscopy

Slide23

Management:

Nonoperative

(80%)

:

High fiber diet

Increase fluid intake

Laxatives

Avoid straining during defecation

Anal hygiene

Topical

nifedipine

Sitz

bath

Botox

Slide24

Surgical (20%)

:Chronic fissures refractory to conservative treatmentLateral internal sphincterotomy (LIS)

Slide25

Anal Abscesses and Fistulas

They may present as acute or chronic manifestations of the same perirectal disease

Slide26

Anal Abscess:

It’s an infection of the soft tissues surrounding the anal canal, with formation of a discrete abscess cavity

Slide27

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%)

Slide28

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

Slide29

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

Slide30

Signs and symptoms:

Severe pain in the anal area (pain is constant and not necessarily associated with bowel movements)

Lump in the anal area

Lower abdominal pain (

pelvirectal

abscess)

Constitutional symptoms ( fever, malaise)

Drainage of pus

Slide31

Management:

Early

incision and

surgical drainage

of the purulent collection

Sitz

bath

Anal hygiene

Laxatives

There is

no role for antibiotics

except for patients who are:

-

Immunocompromised

- Diabetics

- Diagnosed with

valvular

heart diseases

- Diagnosed with

cellulitis

Slide32

Complications:

A potential complication of

anorectal

abscess drainage is the formation of fistulous tracts within 6 months in 50% of cases

Slide33

Anal Fistulas:

They are abnormal connections between the epithelialized surface of the anal canal and the perianal skin

Slide34

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.

Slide35

Etiology:

Opened

perianal

or

ischiorectal

abscesses, which drain spontaneously through these fistulous tracts

Fistulas 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

Slide36

Signs and symptoms:

Recurrent malodorous

perianal

drainage

Pruritus

Recurrent abscesses

Fever

Perianal

pain due to an occluded tract, may have pain during defecation

Slide37

Physical examination:

Digital examination is usually all that is required, assessment of the anatomy of an anal fistula is very important

Digital examination in a patient with a fistula-in-

ano

may reveal an

indurated

tract or cord

Fistula can be identified by small circles of granulation tissue, which exudes pus when compressed if tissue is patent

A fistulous tract that opens internally can be visualized with aid of an

anoscope

Inguinal lymph nodes may be enlarged and painful

In an acute fistulous abscess, cardinal signs of inflammation, (

erythema

, pain, increased temperature, edema) may be found

Slide38

What to asses during physical examination:

Often done in the OR

External opening

Internal 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 tract

Amount of sphincter muscle involved

Slide39

Investigations:

CBC (number of WBC in significant infection), blood culture

Fistulogram

Transanal

US

MRI

CT

Slide40

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

Slide41

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

Slide42

Cutting

seton

Draining

seton

Fistulotomy

Fistula plug

Advancement flap

Slide43

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

Slide44

Fistulotomy

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

Slide45

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

Slide46

Intersphincteric

fistulae

: P

rimary

fistulotomy

Low

Transsphincteric

fistulae

:

Primary

fistulotomy

High

transsphincteric

or anterior fistulae

: I

n female patients should be treated with a more conservative approach, for example a cutting

seton

or a fistula plug as to avoid

fistulotomy

incontinence

Suprasphincteric

fistulae

:

Advancement flaps, sphincter reconstruction or cutting

setons

.

Fistulotomy

should not be performed, to avoid incontinence

Extrasphincteric

fistulae

:

Endorectal

advancement flap

Slide47

Contraindications of fistulotomy:

Anterior fistulas in females

(perform a

seton

to avoid injuring the

perineal

body, due to it’s proximity)

A high level fistula

Patients diagnosed with

Crohn’s

disease

Slide48

Thank you…


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