Document 384312

Introduction
Surgical Anatomy
Congenital
Abnormalities
Examination of
the Anus
Common Anal
Conditions
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Anal and perianal
disorders makeup about
20% of all outpatient
Surgical referrals. These
conditions are extremely
distressing and embarrassing
patient often put up with
symptoms for long time,
before seeking
medical care.
3
The common anal symptoms are;
Anal bleeding
Anal pain and discomfort
Perianal itching and irritation
something coming down
perianal discharge
4
The anal canal
1.5” (4 cm) long
and is directed
downward and
backward from
the rectum to end
at the anal
orifice.
The mid of
anal canal
represents the
junction
between
endoderm and
ectoderm
5
The lower ½ is lined by squamous epithelium
and the upper ½ by columnar epithelium so
carcinoma of the upper ½ is adenocarcinoma.
Where as that arising from the lower part is
squamous tumour.
The blood supply of upper ½ of the anal canal
is from the superior rectal vessels. Where as
that of the lower ½ is supply of the
surrounding anal skin the inferior rectal vessels
which derives from the internal pudendal
ultimately from the internal iliac vessels.
6
The lymphatic above the muco cutaneous
junction drain along the superior rectal
vessels to the lumbar lymph nodes, where as
below this line drainage is to the inguinal
lymph nodes.
The nerve supply to the upper ½ via
autonomic plexus and the lower ½ is supplied
by the somatic inferior rectal nerves terminal
branch of the pudendal nerve. So the lower
½ is sensitive to the prick needle.
7
The anal sphincter:-
This comprises:-
The internal anal sphincter of in voluntary
muscle, which is the contination of the circular
muscles of the rectum.
The external sphincter of the voluntary muscles,
which surrounds the internal sphincter and
comprises 3 parts (formerly)
 subcutaneous the lower most portion of the
external sphincter
 superficial part
 deep part
(now considered to be one muscle)
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There are two main types:• High abnormality more serious because it is
associated with poor development of the
pelvic muscles.
• Low abnormality which is simply to treat:These abnormalities should be diagnosed at
birth is the standard physical examination of
the new born infant. If the diagnosis missed
the infant developed symptoms and signs of
large bowel obstruction.
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High abnormalities:
 The rectum stops short of the
pelvic floor and the anal canal
is absent.
Low abnormalities:
 The abnormality is usually
either ectopic or covered anus.
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Diagnosis:On physical examination.
If the baby fail to produce meconium
stool in the first few hours of life.
Investigation: urine for meconium, if no
meconium is visible the site of the anus
marked with metal and x-ray taken for the
baby up side down so gas shadow may
helps to show the distal point of bowel
development.
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Treatment:-
need early and vigorous treatment
in infancy.
Low abnormalities: should be treat by
“cutback type operation” followed by
regular digital dilatation by the mother.
High abnormalities: should be treated by
colostomy in the 1st few days followed by
some sort “pull through operation” at the
age of one year.
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This requires careful attention to circumstances (couch, light,
gloves). The Sims (left lateral position) is satisfactory. The
examination proceed by;




inspection
digital examination with index finger
proctoscopy
sigmoidoscopy
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








Rectal prolapse
Anal in continence
Haemorrhoids
Pruritus ani
Anorectal abscess
Anal fissure
Anal fistula
Non malignant strictures
Anal neoplasms
14
Normal anal continence
depends on an intact
spinal cord reflex acting
on an adequate sphincteric
mechanism under cortical
inhibitory control.
15
Causes of incontinence: Congenital malformations of the anus in which the




sphincter is partially or completely lacking.
Trauma. e.g accidental injury, obstetrical tears or
operative trauma
Anorectal disease e.g. rectal prolapsed, piles,
chronic inflammatory bowel disease, faecal
impaction, destruction as carcinoma of anus.
Medical conditions e.g., mental deficiency, senility
and spinal cord lesions.
Neurological and physiological diseases e.g. spina
bifida, spinal tumours and trauma.
16
Clinical Features:
The following are the clinical
types:
A
True incontinence
B
Partial incontinence
C
Overflow incontinence
17
There is no satisfactory treatment
many causes of incontinence.
TREATMENT:
for
A
Conservative measure: satisfactory for minor
degree
of incontinence e.g., anorectal lesion,
faecal impaction
and the sphincter tone
improved
by daily exercises.
B
Operative treatment: this depend on the causes of
incontinence.
 Thiersch’s operation
 Obstetrical injury (coloperincorrhaphy)
 Sphincteroplasty in cases of traumatic post
operative incontinence.
 Sphincter reefing
 Colostomy
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Piles may be internal or external
according to whether they are
internal or external to anal
orifice.
The internal Haemorrhoids:
 They are dilation of the superior
haemorrhoidal veins above the denate
line each pile consists of mass of dilated
vein, artery, some connected tissues and
mucosal investment.
19
 The location of piles, right anterior,
right posterior and left lateral situated
respectively 11, 7, 3 o’clock with
patient in the lithotomy position, these
are give daughter piles.
 Degree of piles: there are four degree
of piles.
Aetiology of Haemorrhoids: the causes
may be primary or secondary.
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Primary Causes:
These are attributed to several
predisposing causes:
 Hereditary factors e.g, structural
weakness of the vein.
 Anatomical factors.
 Partial congestion.
 Chronic constipation.
 Sphincteric relaxation.
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Secondary Causes:
as;
These are due to underlying organic cause such
 pregnancy




venous obstruction
straining on micturation
venous congestion
carcinoma of the rectum
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Clinical features of Piles:
 Bleeding at defecation
 Prolapse
 Discharge with pruritus ani
 Pain
 Thrombsed piles
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Assessment and Diagnosis:
 Careful history
 Abdominal Examination
 Anorectal Examination
 Investigation e.g., proctoscopy
Complications of Piles:
 Profuse haemorrhage
 Acute thrombosis
24
Treatment of Piles:
 Conservative treatment
 Specific treatment
 Injection treatment
(Gabriel syringe is filled with sclerosat 5%
phenol with almond oil)
 Barron’s rubber banding
 Cryosurgery (using cryosurgical probe and
liquid nitrogen)
 Co2 Laser
 Lord’s manual dilation
 Haemorrhoidectomy
25
External Haemorrhoids:
(Perianal Haematoma)
due to rupture of dilated anal vein as result of
sever straining.
 sudden onset of painful lump at the anus.
 o/e swelling tense & tender, bluish in colour covered with
smooth shining skin.
 Treatment: LA evacuation if the patient come within
48h0, if patient come late conservative treatment.
 if untreated the haematoma undergoes:
 resolution
 ulceration
 supporation to forms in abscess
 fibrosis which give rise to skin tag.
26
Rectal Prolapse:
Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse when the mucous
membrane lining the anal canal protrudes through
the anus only.
 Complete prolapse in which the whole thickness of
the bowel protudes through the anus.
Rectal prolapse occurs most often at extremes
of life e.g, in children between 1-5 years of
age and elderly people. More common in
female than male.
27
In children:
the predisposing causes are:-
 The vertical straight course of the
rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.
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In adult: the predisposing causes depend
on type of the prolapse.
Partial prolapse




Advance degree of prolapsing piles.
Loss of sphincteric tone.
Straining from urethral obstruction.
Operations for fistula.
Complete prolapse
is generally regarded as
sliding hernia of the recto vesical or recto
vaginal pouch due to stretching of the levator
and from pregnancy, obesity.
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 Prolapse is first noted during defaecation.
 Discomfort during defaecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to
incontinence.
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Complications of rectal prolapse:




Irreducibility
Infection
Ulceration
Severe haemorrhage from
one of the mucosal vein
 Thrombosis and obstruction of
the venous returns leading to oedema
 Irreducibility and gangrene
31
the prolapse tends to
disappear spontaneously by the age of 5
years. So conservative measures are
sufficient.
Prolapse in children:
 Conservative treatment: constipation and
straining at stool are avoided and the buttocks
may be strapped together to discourage
prolapse during defaecation.
 Perirectal injection of alcohol/phenol may be
used to fix the lax mucosa to underlying tissue.
32
Partial prolapse:
 Provided sphincter tone is satisfactory can be
treated by ligature excision of prolapsed
mucosa.
 Injections of 5% phenol in oil in submucosa.
10-15ml total.
 Electrical stimulation with sphincteric exercises.
33
Complete prolapse:
Surgery always necessary, none are ideal.






Thiersch’s operation
Rectopexy (lock haurt)
Rectosigmoidectomy (Mikulicz’s op.)
Ivalon sponge rectopexy (Well’s op.)
Ripstein operation
Low anterior resection (minor)
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Pathology:
The infection usually starts in one
of the crypts of Morgagni and extends along the
related anal gland to the inter sphincteric plane
where it forms as abscess. Soon it tracks in
various directions to produce different types of
abscesses which are classified as follows:
 Perianal abscess (60%)
 Ischiorectal abscess (30%)
 Sub mucous abscess (5%)
 Pelvirectal abscess
NOTE: Patient with recurrent anorectal abscess always
consider associated underlying diseases such as
Crohn’s, UC, rectal cancer and active TB.
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Symptoms:-
Signs:-
Treatment:-
 Acute pain
 High fever
 Swelling
 Tenderness with
induration
Incision and drainage and
covered by antibiotics.
36
 Fistula in ano
 Recurrence
 Inflammatory bowel
disease
37
Defined as track lined by granulation
tissues, which connects deeply in the
anal canal or rectum and superficially
on the skin around the anus. It usually
result from an anorectal abscess.
However the aetiology is uncertain.
Anal fistulas have well recognized
association with crohn’s disease, UC,
TB, colloid carcinoma of the rectum and
lympho granuloma venercum.
38
Types of Anal Fistulas:
A
According to whether their natural
opening is below or above the
anorectal ring
 Low level e.g., subcutaneous, low
anal, sub mucous.
 High level – open into anal canal
at or above the anorectal ring
e.g., high anal, pelvirectal
39
B
Parks classification according to
relation of anal sphincter: Inter sphincteric (70%) low level
anal fistula
 Trans-sphincteric (25%) high
level anal fistula
 Supra sphincteric fistulae (4%).
 Extra sphincteric (1%) rare type
include the tract passes outside
all sphincter muscles to open in
the rectum.
40
Good Sall’s Rule
 Fistulas with external opening in
relation to the anterior ½ of the anus
tend to be direct type.
 Those with external opening in
relation to the posterior ½ of the
anus
usually tends to open internally
in the posterior midline. May extend
behind the anal canal or both sides
forming
horse shoe fistula.
41
The chief symptoms is persistent
discharge which irritates the skin and
causes discomfort at the anus may be
associated with pain.
O/E
external opening may be seen with
palpation the tracks is often palpable
as cord. P/R examination.
42
Investigation
 Proctoscopy
 Radiology
 Biopsy
TREATMENT
(Fistulectomy) always sent
track for Bx.
43
Defined as longitudinal tear in
the mucosa and skin of the anal
canal. Commonly posterior
midline more common in female
than male. Lateral fissures are
so rare there presence suggest
specific lesions such as, Crohn’s
disease, UC, TB or malignancy.
44
Aetiology
may be due to:
 Tearing of the anal lining by over
distension
of the anal canal during
passage of large scybalous mass (stool).
 Tearing of anal valve or fibrous polyps.
 Laceration of the anal canal by sharp FB.
 Excessive straining during child birth.
45
The acute anal fissure if not treated
becomes chronic anal fissures. As result
secondary pathological changes may
occurs:





Chronicity
A “sentinel” pile
Hypertrophied anal papilla
Contracture of the anus
Suppuration
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Usually affect, young or middle aged adult,
common in female than male. Rare in old
age may occur in infancy and may cause
acquired mega colon.




Pain during and after defecation.
Constipation
Bleeding
Discharge
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 Fissure or ulcer distal to
dentate line.
 Sentinel Tag
 Hypertrophied papilla.
 Spasms of the internal
sphincter
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TREATMENT
A
B
Conservative Treatment
 Stool softeners (laxative)
 Sitz baths (10 – 15 mins.)
 Ointments & Suppository
Surgical Treatment
 Dilation under anaesthesia (Anal
Stretch)
 Fissurectomy and dorsal
sphincterotomy
 Lateral internal sphincterotomy
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BENIGN STRICTURES
Aetiology:
Stricture of the anus
and rectum may be:
 Congenital
 Postoperative
 Inflammatory
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1
Progressive difficulty in defaecation
2
In cases of inflammatory strictures




Bleeding
Discharge
Tenesmus
Late cases subacute int. obst.
Note: (Pipestem Stools)
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Diagnosis:
Investigations:
Treatment:
Rectal examination reveals
the location type and degree
of the stenosis.
 Proctoscopy
 Biopsy
 Dilation
 Superficial external
proctotomy
 Internal proctotomy
52
Benign Tumours
1
Epithelial Tumours
a.) Anal warts (virus)
b.) Juvenile polyp
c.) Adenomatous polyps
d.) Villous papilloma
e.) Familial polyposis
f.) Pseudo polypi
g.) Endo Metrioma
53
2
Connective Tissue Tumours
a.) Fibrous polyp
b.) Lipoma
d.) Myoma
e.) Haemangioma
f.) Benign Lymphoma
54
The lesion is usually squamous
cell carcinoma.
Rarely adenocarcinoma,
malignant melanoma or basal
cell carcinoma.
55
Squamous cell carcinoma
Arising from the stratified squamous
epithelium of the lower ½ of the anal
canal. It is uncommon and forms less
than 5% of all anorectal malignancies.
It is disease of elderly squamous cell
carcinoma more common in males.
The aetiology of anal carcinoma
unknown but chronic irritation or
infection may be predisposing factors.
56
Clinical Features
with:
the patient may present
 localized ulcer or raised growth with
irregular ulcerated surface.
 History of bleeding.
 History of pain with discomfort.
 Tenesmus with incontinence.
 Discharge.
57
O/E

On palpation squamous carcinoma
feels hard and woody due to
invasion of perianal tissues.

P/R examination may prove
impossible because of stenosis
or discomfort.

Inguinal LN are examined
carefully as they receive lymph
from the lower anal canal and
perianal region and may be the
site of metastasis.
58
 The squamous carcinoma divided into two
types that spreading above the pectinate line
and that confined
below that line.
 Those above the pectinate line treated by
abdomino perineal excision as for rectal
adenocarcinoma.
 Those below the pertinate line.
• local excision.
• if inguinal LN metastasis present
should be removed by block dissection.
 Palliative colostomy late cases.
 Radiotherapy.
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Rare Malignant Anal Tumours
 Adenocarcinoma
 Basal cell carcinoma
 Malignant melanoma
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