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    Back To Medical School: - Anorectal Disorders

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    SemSem
    This document discusses the examination and treatment of various anorectal disorders. It covers common symptoms, examination techniques, and treatments for conditions such as hemorrhoids, fistulas, fissures, abscesses, and anal cancer. Examination involves inspection of the external and internal anus. Treatment depends on the specific diagnosis but may include dietary changes, medications, injections, surgery, or radiation and chemotherapy for cancer. The goal is to treat underlying causes, relieve symptoms, and preserve continence when possible for surgical procedures.

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    Back To Medical School: - Anorectal Disorders

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    SemSem
    398 views54 pages
    This document discusses the examination and treatment of various anorectal disorders. It covers common symptoms, examination techniques, and treatments for conditions such as hemorrhoids, fistulas, fissures, abscesses, and anal cancer. Examination involves inspection of the external and internal anus. Treatment depends on the specific diagnosis but may include dietary changes, medications, injections, surgery, or radiation and chemotherapy for cancer. The goal is to treat underlying causes, relieve symptoms, and preserve continence when possible for surgical procedures.

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    Anorectal Conditions

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    This document discusses the examination and treatment of various anorectal disorders. It covers common symptoms, examination techniques, and treatments for conditions such as hemorrhoids, fistulas, fissures, abscesses, and anal cancer. Examination involves inspection of the external and internal anus. Treatment depends on the specific diagnosis but may include dietary changes, medications, injections, surgery, or radiation and chemotherapy for cancer. The goal is to treat underlying causes, relieve symptoms, and preserve continence when possible for surgical procedures.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    398 views54 pages

    Back To Medical School: - Anorectal Disorders

    Uploaded by

    SemSem
    This document discusses the examination and treatment of various anorectal disorders. It covers common symptoms, examination techniques, and treatments for conditions such as hemorrhoids, fistulas, fissures, abscesses, and anal cancer. Examination involves inspection of the external and internal anus. Treatment depends on the specific diagnosis but may include dietary changes, medications, injections, surgery, or radiation and chemotherapy for cancer. The goal is to treat underlying causes, relieve symptoms, and preserve continence when possible for surgical procedures.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 54

    Back to medical school

    -anorectal disorders

    Ian Botterill, Dept Colorectal Surgery


    Leeds General Infirmary
    Wide variety of pathologies
    • congenital / acquired

    • benign / malignant
    • traumatic
    • infective / inflammatory
    • gender / age related
    Common symptoms of ano-rectal
    disorders
    • bleeding
    • anal pain
    • itch
    • faecal leakage / hygiene problems
    • swelling
    • discharge
    Examination
    • abdomen
    • groins (lymph nodes)
    • dermatoses
    Ano-rectal examination

    • chaperoned
    • relaxed patient
    • left lateral
    • good light
    • knee elbow position
    • use pt’s hand to elevate
    right buttock
    • +/- anoscopy in 1y care
    Ano-rectal examination

    • External appearance • Digital examination


    -skin condition -sphincter tone
    -swellings -squeeze pressure
    -soiling / discharge -cervix / prostate
    -perineal descent -coccyx
    -scars -retrorectal space
    -rectocoele
    Anatomy
    Haemorrhoids
    • Symptoms:
    - anal canal bleeding, pruritus, swelling, pain
    Haemorrhoids
    • Classification
    - 1y: bleed, do not prolapse
    - 2y: prolapse & reduce spontaeously
    - 3y: prolapse & require manual reduction
    - 4y: prolase, not reducible
    Cause of haemorrhoidal problems

    • altered bowel habit


    • raised intra-abdominal pressure
    • straining
    Treatment of haemorrhoids
    • Diet
    -five helpings fibre / d
    • Out-patient
    -injection sclerotherapy
    -banding
    -photocoagulation
    Surgical treatment
    • For 3rd / 4th degree haemorrhoids

    • Open haemorrhoidectomy
    • Closed haemorrhoidectomy
    • Ligasure haemorrhoidectomy

    • Stapled haemorrhoidopexy (PPH)


    Results of haemorrhoidectomy
    • >90% daycase
    • least initial pain
    -stapled haemorrhoidopexy
    -Ligasure haemorrhoiodectomy
    • quickest return to work:
    -stapled haemorrhoidopexy
    -Ligasure haemorrhoidectomy
    • most costly: PPH / ligasure
    • lowest recurrence (prolapse) ; conventional
    Complications of
    haemorrhoidectomy
    • Local
    - stenosis
    - faecal leakage
    - recurence
    - bleeding
    - retention of urine

    • severe perineal sepsis (esp IDDM &


    immunosuppressed)
    Painful prolapsed haemorrhoids

    • natural history (worst pain days ~ 3-7, then settles)

    • most resolve with conservative Rx


    - lactulose / topical anaesthetic creams / ice / paracetamol & NSAIDs /
    relief of anal spasm (GTN or diltiazem)
    - failure to resolve > haemorrhoidectomy
    - refer gangrenous or those that fail to settle

    • interval haemorrhoidectomy if still problematic


    Anal skin tags

    Sx: anal swelling / hygiene problems


    Diagnosis: perineal examination alone
    Differential: Crohn’s disease / anal warts
    Rx: reassurance / excision
    Rectal mucosal prolapse & full
    thickness rectal prolapse
    Rectal mucosal prolapse
    • result of straining
    • associated with pruritus ani / mucous
    discharge
    • diagnosis @ anoscopy
    • Rx
    - dietary correction
    - advised to avoid straining at stool
    - injection sclerotherapy
    Ano-rectal sepsis

    Sx: perineal pain (throbbing), possible prior history of similar


    Exam: tender fluctuant mass +/- discharge, may be toxic
    Beware: diabetics (risk of rapidly progressive infection & Fournier’s gangrene)
    skin necrosis (possible Fournier’s gangrene)
    anal spasm & throbbing pain (inter-sphincteric abscess)
    Treatment: I&D
    Fistula in ano

    ~ 30-40% of all perineal sepsis once drained goes on to develop


    a fistula
    ~ 80-90% of perineal sepsis that yielded enteric organisms will
    develop a fistula
    Fistula in ano
    • 95% cryptoglandular
    - ie origin in ano-rectal crypts at dentate line

    • 5% rarities
    - Crohn’s
    - TB
    - hidradenitis suppurativa
    - traumatic
    - malignancy
    - complicated diverticular disease
    - radiation
    - anastomotic leakage
    Classification
    Inter-sphincteric 70%
    Trans-sphincteric 25%
    Supra-sphincteric ~5%
    Extra-sphincteric <1%

    Simple v. complex

    ‘Complex’:
    -branching tracts / 2y tracts
    -associated abscess
    -associated pathology
    Goodsall’s rule

    External opening posterior to 3-9


    oclock position open in posterior
    midline of the anal canal

    External opening anterior to 3-9 oclock


    position open radially in the anal canal

    ~80-90% accurate
    Management of fistula in ano

    Strike a balance between


    -cure of fistula
    -prevention of further anorectal abscess
    -preservation of continence
    Management of fistula in ano
    • Divide tissues overlying track ( to allow healing by 2y
    intent)
    - lay open
    - cutting seton

    • Occlude internal opening & provide external drainage

    - anal fistula plug


    - rectal or anal advancement flap

    • Prevention of further ano-rectal sepsis


    - draining seton
    Anal fissure
    • ‘focal linear deficiency of anal mucosa’

    • posterior > anterior

    • acute v. chronic
    -chronic: IAS exposed , > 6/52, keratinisation

    • simple v. complex
    Anal fissure
    Anal fissure management
    • stool softeners
    • dietary advice
    • topical LA

    • chemical sphincterotomy
    -topical
    -injected
    • surgical sphincterotomy
    Anal fissure surgery through the
    ages
    • anal stretch
    • lateral sphincterotomy

    • chemical sphincterotomy
    - topical
    - injectable
    Anal fissure treatment
    • GTN 40-50% successful
    s/e: severe headaches
    • Diltiazem 60-80% successful
    s/e: nil generally
    • Botox 60-90% successful
    s/e transient minor leakage
    • Sphincterotomy 98% successful
    s/e 2% passive leakage
    Proctitis
    • Biopsy mandatory (with exception of prior
    prosate / cervical brachytherapy)

    • UC / Crohn’s / indeterminate / infective

    • Stool culture

    • Biopsy prior to starting suppositories

    • Suppositories often preferable to oral therapy


    Pilonidal sinus / & abscess

    Abscess often deep-seated – do not respond to antibiotics


    Pilonidal sinus disease
    Z plasty

    Uli Szymanovski
    Developed ‘Z’ plasty wound closure
    Rhomboid flap

    Healing by 1y intention ~90% of time as with Z plasty


    Healing by 2y intent
    Healing using Vac Therapy
    Perianal haematoma
    • Thromobosis of superficial haemorrhoidal
    veins

    • Discrete circular lump at / beyond anal


    verge

    • Incise & drain


    Pruritus ani

    Night > day


    Rule out coexistent dermatoses / renal failure / liver disease
    If fungal disease suspected > skin scrapings
    Ano-rectal examination & proctoscopy.
    Treat ano-rectal pathology (haemorrhoids / faecal incontinence / anal
    tags etc).
    Pruritus treatment
    • Avoid synthetic / tight underwear
    • Avoid perfumed soaps etc
    • Avoid scratching
    • Use hairdryer to dry skin
    • Avoid steroid creams
    • Treat anal pathology / diarrhoea
    • Dermatology involvement

    • Methylene blue injections > ~80% successful


    - s/e occasional cellulitis / ulcer /
    incontinence
    Faecal incontinence
    - understand continence first!
    • Brain / higher centres
    • Spinal cord
    • Reflex arcs
    • Pudendal nerves
    • Ano-rectal sensation ‘sampling’
    • Stool consistency
    • Rectal compliance
    • Anal sphincter complex
    Faecal incontinence
    • Causation

    • Obstetric injury (8-30% sphincter injury rate at childbirth)

    • Post-surgical
    • Faecal impaction
    • Neuropathy / MS / Parkinson’s
    • Poor mobility / impaired cognition
    • Diarrhoea
    • IBS / rectal non-compliance
    Assessment of faecal incontinence
    • History
    • Examination

    • Endoanal USS (sphincter injury)

    • Anorectal manometry (rest & squeeze strength)

    • Pudendal nerve terminal latency (sensation)


    Assessment of incontinence
    • Cleveland clinic score - severity of soiling - frequency of
    soiling - use of pads - lifestyle disruption

    • History of back injury / neurolgical disorder

    • Urinary incontinence

    • Saddle anaesthesia
    Treatment incontinence
    • dietary measures
    • treat diarrhoea / impaction / IBS
    • non-operative
    - collagen injections
    - anal plug
    • sacral nerve stimulation
    • sphincter repair
    • artificial sphincters
    • graciloplasty
    Anal stenosis
    • Post-surgical
    • Cancer
    • Crohn’s
    • Previous chronic anal fissure

    • Radiation
    • Systemic sclerosis

    • Need EUA to assess all these


    Anal cancer

    Sx: itch, bleeding, pain (if below dentate line), swelling,


    ulcer, groin node
    Exam: hard, irregular, friable area. Groin nodes possible. ?
    Coexists with anal warts
    Differential: haemorrhoids, anal fissure, anal warts, STD
    Diagnosis: EUA & biopsy
    Anal cancer
    -treatment
    • Chemo-radiotherapy
    • Ongoing perineal surveillance
    • Average local control ~ 70%
    • Average cure ~ 70%
    • Salvage surgery for recurrence
    - APER with rectus flap to perineum

    • Rarely is local excision alone sufficient


    Hidradenitis suppurativa

    Superficial fistulating condition ass’d with chronic skin sepsis


    Axillae > groins > perineum
    Clinical diagnosis (+/- biopsy) – typically have disease elsewhere
    Rx: drain sepsis / rotating antibiotics / infliximab / stop smokng
    Anal papillae

    Sx: nil (asymptomatic finding typically)


    Diagnosis: at anoscopy
    Biopsy: rarely required
    Treatment: leave alone
    AIDS & the perineum
    • Wide variety of pathology
    - fissures / abscesses / fistulae / infections / anal
    cancer / cutaneous lymphoma
    - florid warts
    - pruritus
    - incontience

    • General principle
    - suspect immunocompromise
    - culture / biopsy
    - avoid agresssive surgery
    - treat in conjunction with Infectious Diseases
    / Sexual Health
    AIDS

    HSV
    Other perineal problems
    -pressure sores

    Post-sacral
    Over ischial tuberosity
    Normally have clear cut antecedant history
    summary
    • diverse pathology
    • high degree of overlap between 1y and 2y
    care
    • refer bleeding
    • refer ‘odd-looking’ lesions

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