Nikshoar MD Colorectal Surgeon Associate Professor Shahid Beheshti Medical University A 45 years old female with rectal bleeding What is your differential diagnosis Rectal Bleeding Hemorrhoid ID: 914331
Download Presentation The PPT/PDF document "Anorectal Disease Mohammad Reza" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Slide2Anorectal Disease
Mohammad Reza
Nikshoar MDColorectal Surgeon (Associate Professor )Shahid Beheshti Medical University
Slide3A 45 years old female with rectal bleeding
What is your differential diagnosis?
Slide4Rectal Bleeding
Hemorrhoid
Colorectyal cancerDiverticulitisAnal fissureRectal polypSolitary ulcerPoroctitsRectal prolapseRectal traumaPreanal abscess
Preanal fistula
Angiodysplasia
colitis
Slide5Hemorrhoid
Definition
Often described as "varicose veins of the anus and rectum", hemorrhoids are enlarged, bulging blood vessels in and about the anus and lower rectum. There are two types of hemorrhoid
Slide6Slide7Hemorrhoid History
Hemorrhoids pre-date Hippocrates, the ancient Greek physician considered to be among the most important figures in the history of medicine.
Hemorrhoids were mentioned by the Egyptians, Indians and all cultures in the ancient world. The oldest anatomical books that mention hemorrhoids are in the Egyptian Ebers papyrus. Estimated to have been written around 3000 BC, it mentions hemorrhoids, rectal prolapse, intestinal parasites etc.Hippocrates treated hemorrhoids by cauterization, excision and ligation. So things haven’t changed that much! We are still treating hemorrhoids by burning, ligation and surgical removal.
Slide8Slide9Epidemiology
They are extremely common and estimated to be present in up to 50 percent of the population by age 50.
Slide10Slide11Symptoms
External hemorrhoids
Rectal pain occurs mainly with external hemorrhoids. Blood may pool under the skin, forming a hard, painful lump. This is called a thrombosed, or clotted, hemorrhoid. You might also notice streaks of blood on the toilet paper after straining to pass a stool. Internal hemorrhoidsThe most common symptom of internal hemorrhoids is rectal bleeding. You may find bright red streaks of blood on the toilet paper or bright red blood in the toilet bowl after having a normal bowel movement. Blood also may be visible on the surface of the stool.
Slide12Slide13What causes hemorrhoids?
Normally, tissue inside the anus fills with blood to help control bowel movements. If you strain to move stool, the increased pressure causes the veins in this tissue to swell and stretch. This can cause hemorrhoids.
Diarrhea or constipation also may lead to straining and can increase pressure on veins in the anal canal.Pregnant women can get hemorrhoids during the last 6 months of pregnancy. This is because of increased pressure on the blood vessels in the pelvic area. Straining to push the baby out during labor can make hemorrhoids worse.Being overweight can also lead to hemorrhoids
Slide14What causes hemorrhoids?
Liver disease, heart disease, or both. These conditions may cause blood to back up in the pelvis and abdomen.
Prolonged sitting or standing. This may cause blood to pool in the anal area and increase pressure on the veins.Frequent heavy lifting or holding your breath when lifting heavy objects. This can cause a sudden increase of pressure in blood vessels
Slide15The diagnosis of hemorrhoids is based on
medical history
physical examdigital rectal examEndoscopyFlexible sigmoidoscopyBarium enemaColonoscopy
Slide16Treatment Overview
Most hemorrhoids can be treated with simple changes to diet and bowel habits
Fixative procedures include tying off the hemorrhoids with a rubber band (rubber band ligation) or using heat, lasers, or electric current to create scar tissue (coagulation therapy).HemorrhoidectomyStapler
Slide17Slide18Slide19Slide20Prevention
Avoid constipation
Include fruits, vegetables, beans, and whole grains in your diet each day. These foods are high in fiber.Drink plenty of fluids, enough so that your urine is light yellow or clear like water.Get some exercise every day. Try to do moderate activity at least 2½ hours a week. Or try to do vigorous activity at least 1¼ hours a week. It's fine to be active in blocks of 10 minutes or more throughout your day and week.
Slide21Take a fiber supplement, such as Citrucel or Metamucil, every day if needed. Start with a small dose and very slowly increase the dose over a month or more.
Schedule time each day for a bowel movement. Having a daily routine may help. Take your time and do not strain when having a bowel movement
Slide22Slide23Prevention
Practice healthy bowel habits
Go to the bathroom as soon as you have the urge.Avoid straining to pass stools. Relax and give yourself time to let things happen naturally.Avoid holding your breath while passing stools.Avoid reading while sitting on the toilet. Get off the toilet as soon as you have finished.
Slide24Prevention
Modify your daily activities
Avoid prolonged sitting or standing. Take frequent short walks.If possible, avoid lifting heavy objects frequently. If you must lift heavy objects, always exhale as you lift the object. Don't hold your breath when you lift.If you are pregnant, sleeping on your side will lower pressure on the blood vessels in your pelvis. This can help keep hemorrhoids from becoming bigger.
Slide25A 18 year old girl with anal pain after
defecation
Anal Fissures
Slide26What
are anal fissures?
An anal fissure is a cut or tear occurring in the anus (the opening through which stool passes out of the body) that extends upwards into the anal canal.
Slide27Epidemiology
Fissures are a common condition of the anus and anal canal and are responsible for 6-15% of the visits to a colon and rectal (colorectal) surgeon. They affect men and women equally and both the young and the old. Fissures usually cause pain during bowel movements that often is severe. Anal fissure is the most common cause of rectal bleeding in infancy
Slide28Slide29What Are Anal Fissures?
When the lining of the anal canal develops a tear or a sore (also called an
ulcer), it is called an anal fissure. The anal canal is the last part of the rectum before the anus. Fissures can occur in just about anyone, but are more common in middle aged or young adults. A fissure can be difficult to heal because it causes a spasm in the anal sphincter and aggravates itself, creating a vicious cycle of pain and irritation.
Slide30EPIDEMIOLOGY
It is estimated that there are approximately 100,000 cases per year in the United States
The mean age for presentation of anal abscess and fistula disease is 40 years (range 20 to 60Adult males are twice as likely to develop an abscess and/or fistula compared with women The incidence of anal fissures is around 1 in 350 adults. They occur equally commonly in men and women and most often occur in young adults aged 15 to 40.
Slide31Causes
Anal sex
Constipation Crohn's disease Chronic use of laxatives Immunodeficiency disorders Leukemia Multiple pregnancies
Slide32What are the symptoms of anal fissures
pain that worsens with bowel movements.
Bleeding itching (pruritus ani), malodorous discharge BurnEczemaFistula
Slide33Slide34How are anal fissures diagnosed and evaluated?
A careful history
gentle inspectiontag of skin at the edge of the anus (sentinel pile),anal papilla at the upper end of the fissureSigmoidoscopy
Slide35Slide36What causes anal fissures?
Trauma
Hard stool DiarrheaInsertion of a rectal thermometerEnemaEndoscopeUltrasound probe
Slide37How are anal fissures treated?
The goal of treatment for anal fissures is to break the cycle of spasm of the anal sphincter and its repeated tearing of the
anodermfiber diet. Additionally, patients are advised to avoid "sharp" foods that may not be well-digestedSitz bathsAnesthetics and steroids
Slide38surgery.
nitroglycerin.
botulism toxinDiltiazemAnal dilatation
Slide39Slide40Prognosis
The prognosis is good for acute fissures; they generally heal with non-invasive treatments. The cure rate using LIS surgery for chronic fissures is also encouraging. LIS can be repeated if the fissure does not heal with the first surgery. Fissures do not cause cancer and complications are uncommon.
Slide41Slide42Slide43A 28 year man with chills
and fever
He has pre anal pain tooAnorectal Abscess
Slide44Anorectal abscess
There are four types of anorectal abscesses: perianal, ischiorectal, intersphincteric, and supralevator.
Slide45Incidence
More common in males than in females . This differences this is due to (a) Anal cleanliness (b) Rougher type of undergarments causing greater friction on the perineal skin (c) Increase sweating in the anal region .
Slide46Classification
PerianalIscheorectalSubmucous Pelvirectal
Slide47Clinical Features
acute pain
sneezing and defaecation.swelling near the anus which is extremely tender on touching. discharge of pus moderate fever fluctuation can be elicited indurated bulge
Slide48Aetiology
Abrasion or tearing of the lining of the anal canal or of the perianal skin
Infection from an anal crypt via an anal gland . This theory has recently accured greater acceptanceBlood Borne Infection Additional aetiological factors Crohn's disease, Ulcerative colitis and tuberculosis
Slide49Aetiology
Dorsal anal fissure.
Anal hematoma.Prolapsed thrombosed internal hemorrhoids.Following injection of a anaesthetic solution or alcohol in perianal or ischiorectal space in the treatment of perianal pain.Following injection of internal hemorrhoids is less frequent complication but may lead to abscess formation.Injury to anal or rectal mucosa by nozzle of enema syringe.
As a complication of
hemorrhoidectomy
operation
Slide50Slide51Slide52Slide53Signs and Symptoms
Pain
Constipationdrainage from the rectumfever and chillspalpable mass near the anusFatigueNight SweatPainful bowel movements
Slide54Diagnostic approach
medical history
physical exampelvic CT scanMRItrans-rectal ultrasound
Slide55Treatment
Slide56Slide57Slide58A 32 year old man with history of pre anal
abscess
and pre anal dischargeFistula
Slide59Slide60Slide61Fistula
Is an abnormal connection or
pathway between two epithelium-lined organs that normally do not connect
Slide62Symptoms
excrete pus
sometimes serous fluid and rarely fecespruritus aniItchingskin maceration. recurrent abscess formation
Slide63Diagnosis
History
PEinstillation of methylene blue solutionFistulographyMRIEndosonography
Slide64Slide65Therapy
Surgery
(fistulotomy – fistulectomy – seton insertion - curettage and ….)Mucosal advancement flap- MarsupializationNon surgery (glue – plug -laser……..)
Slide66Slide67Slide68Slide69Slide70Slide71Slide72Slide73Slide74Pilonidal Disease
What is your diagnosis about an 18 years old man who complains of inter gluteal pain?
Slide75Pilonidal disease
was first reported in 1833. This process was first described by Anderson in 1847 and later named pilonidal sinus by Hodges ...
Slide76Pilonidal
disease (cyst, infection) consists of a
hair-containing sinus or abscess occurring in the intergluteal cleft.Although the etiology is unknown, it is speculated that the cleft creates a suction that draws hair into the midline pits when a
patients sits
.
These
ingrown hairs may then become infected
and present acutely
as an abscess in the sacrococcygeal region.
Once an acute
episode has resolved, recurrence is
common.
Pilonidal Disease
Slide77Pilonidal disease
is a chronic skin infection in the crease of the buttocks near the coccyx (tailbone). It is more common in men than women and most often occurs between puberty and age 40. Obesity and thick, stiff body hair make people more prone to
pilonidal disease.
Slide78Slide79Treatment
An acute abscess should be incised and
drained as soon as the diagnosis is made.In chronic patient total excision is choice
Slide80