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Benign Anorectal DiseasesBenign Anorectal Diseases
Dr Jamal HamdiDr Jamal Hamdi
ContentContent
HaemorrhoidsHaemorrhoids
Anorectal AbscessAnorectal Abscess
Anal fistulaAnal fistula
Anal fissureAnal fissure
Benign Anal TumorsBenign Anal Tumors
Rectal ProlapseRectal Prolapse
Pilonidal SinusPilonidal Sinus
ProctitisProctitis
Pruritis AniPruritis Ani
Anatomy of the RectumAnatomy of the Rectum
Length:Length: 12 cm. 12 cm.
Diameter:Diameter: Upper part Upper part same of sigmoid same of sigmoid (4cm) but lower is dilated (rectal ampulla).(4cm) but lower is dilated (rectal ampulla).
Beginning:Beginning: rectosigmoid junction (sacral rectosigmoid junction (sacral promontory).promontory).
End:End: 2.5 cm below and in front of the tip of 2.5 cm below and in front of the tip of coccyx.coccyx.
Anatomy of rectumAnatomy of rectumMaleFemale
AnteriorBladderSeminal vesicles
UretersProstateUrethra
Pouch of douglasUterusCervix
Posterior vaginal wall
LateralLateral ligMiddle rectal A.
Obturator internus MSide wall of pelvis
Levator ani M
Lateral ligMiddle rectal A.
Obturator internus MSide wall of pelvis
Levator ani M
PosteriorSacrum and coccyxLoose areolar tissueFacial condensation
Superior rectal ALymphatics
Sacrum and coccyxLoose areolar tissueFacial condensation
Superior rectal ALymphatics
Anatomy of rectumAnatomy of rectum
Arterial SupplyArterial Supply
Superior rectal artery (chief artery)Superior rectal artery (chief artery)
Middle rectal arteryMiddle rectal artery
Median Sacral arteryMedian Sacral artery
Anatomy of Anal CanalAnatomy of Anal Canal
Length:Length: 4 cm 4 cmExtent:Extent: from anorectal from anorectal
junction to the anus.junction to the anus.Interior:Interior:
Upper part:Upper part:Anal columnAnal columnAnal valveAnal valveAnal sinusAnal sinusDentate lineDentate line
Middle part:Middle part:Lower Part:Lower Part:
Anatomy of Anal CanalAnatomy of Anal Canal
Musculature:Musculature:1.1. External anal sphincterExternal anal sphincter
2.2. Internal anal sphincterInternal anal sphincter
Arterial supply:Arterial supply:– Superior and inferior Superior and inferior
rectal arteries.rectal arteries.
Venous Drainage:Venous Drainage:
Lymphatic Drainage.Lymphatic Drainage.
Clinical Features of Anorectal Clinical Features of Anorectal DiseaseDisease
1.1. Bleeding.Bleeding.
2.2. Pain.Pain.
3.3. Altered bowel habit.Altered bowel habit.
4.4. Discharge.Discharge.
5.5. Tenesmus.Tenesmus.
6.6. Prolapse.Prolapse.
7.7. Pruritis.Pruritis.
8.8. Loss of weightLoss of weight
InvestigationsInvestigations
ProctoscopeProctoscopeInspect (10-12 cm)Inspect (10-12 cm)Biopsy can be takenBiopsy can be taken
Sigmoidoscope Sigmoidoscope Lighted tube 2 cm in diameter.Lighted tube 2 cm in diameter.20 to 25 cm long.20 to 25 cm long.Reaches 20 to 25 cm from the dentate line.Reaches 20 to 25 cm from the dentate line.20 to 25 % of colorectal tumors.20 to 25 % of colorectal tumors.Safe and effective for screening low-risk adults Safe and effective for screening low-risk adults under 40 years of age.under 40 years of age.An enema is sometimes used to prepare the An enema is sometimes used to prepare the patient before the examination.patient before the examination.
InvestigationInvestigation
Flexible sigmoidoscopeFlexible sigmoidoscope
A fiberoptic scope.A fiberoptic scope.
Measures 60 cm in length.Measures 60 cm in length.
Reach the proximal left colon or even the splenic Reach the proximal left colon or even the splenic flexure.flexure.
50 % of colorectal cancers.50 % of colorectal cancers.
Every 5 years beginning at age 50 is the current Every 5 years beginning at age 50 is the current endoscopic screening method recommended for endoscopic screening method recommended for asymptomatic persons at average risk for colorectal asymptomatic persons at average risk for colorectal carcinoma.carcinoma.
HemorrhoidsHemorrhoids
DefinitionDefinition– InternalInternal– ExternalExternal– Interno-ExternalInterno-External
SitesSites
1.1. Left lateral (3 o’clock).Left lateral (3 o’clock).
2.2. Right posteriolateral (7 o’clock).Right posteriolateral (7 o’clock).
3.3. Right anterolateral (11 o’clock).Right anterolateral (11 o’clock).
HemorrhoidsHemorrhoids
ClassificationClassification
1.1. 11stst degree degree
2.2. 22ndnd degree. degree.
3.3. 33rdrd degree. degree.
4.4. 44thth degree. degree.
How hemorrhoids causes bleeding?How hemorrhoids causes bleeding?
HemorrhoidsHemorrhoids
DiagnosisDiagnosis
ComplicationComplication
Treatment of HemorrhoidTreatment of Hemorrhoid
11stst degree degree
ConservativeConservative
Dietary adviseDietary advise
Bulk laxativesBulk laxatives
Sitz bathSitz bath
Treatment will be effective at 6 monthTreatment will be effective at 6 month
Treatment of hemorrhoidsTreatment of hemorrhoids
22ndnd degree degree
Rubber band ligation.Rubber band ligation.
Complication of band Complication of band – HemorrhageHemorrhage– SepsisSepsis– PainPain
33rdrd degree degree– HemorrhoidectomyHemorrhoidectomy
Treatment of hemorrhoidsTreatment of hemorrhoids
Complication of hemorrhoidectomyComplication of hemorrhoidectomyAcute urinary retentionAcute urinary retentionSecondary hemorrhageSecondary hemorrhageAnal stenosisAnal stenosis
Thrombosed hemorrhoidThrombosed hemorrhoidConservative (laxative, analgesic, ice Conservative (laxative, analgesic, ice packs)packs)Operative manual dilatation of the anus Operative manual dilatation of the anus and hemorrhoidectomyand hemorrhoidectomy
Anorectal AbscessAnorectal Abscess
Definition: Infection in one or more of anal Definition: Infection in one or more of anal spaces, usually is bacterial infection of spaces, usually is bacterial infection of blocked anal gland at dentate line.blocked anal gland at dentate line.
OrganismsOrganisms– EcoliEcoli– Staph aureus.Staph aureus.
Anorectal AbscessAnorectal Abscess
SitesSites
1.1. Perianal.Perianal.
2.2. Ischiorectal.Ischiorectal.
3.3. Pelvirectal.Pelvirectal.
4.4. Intersphincteric.Intersphincteric.
Increase incidence with?Increase incidence with?
Anorectal AbscessAnorectal Abscess
HistoryHistory
Age, sex, symptomsAge, sex, symptoms
Examination:Examination:
PositionPosition
TendernessTenderness
Color / tempColor / temp
Shape, size, compositionShape, size, composition
Lymph drainageLymph drainage
Local tissueLocal tissue
General ExaminationGeneral Examination
Anorectal AbscessAnorectal Abscess
InvestigationInvestigation
TreatmentTreatment
Incisional and drainageIncisional and drainage
AntibioticsAntibiotics
Fissure-in-ano (anal fissure)Fissure-in-ano (anal fissure)
Definition:Definition:
Acute & chronicAcute & chronic
Longitudinal split in the skin of the anal Longitudinal split in the skin of the anal canal.canal.
Common sites:Common sites:– Midline 6 and 12 o’clock.Midline 6 and 12 o’clock.
Rarely associated with crohns, HSV, HIV.Rarely associated with crohns, HSV, HIV.
Fissure-in-anoFissure-in-anoDiagnosisDiagnosis
TreatmentTreatment
Non- operativeNon- operative– Stool softeners and laxatives Stool softeners and laxatives – Improve hygiene.Improve hygiene.– Anesthetic suppositories may be helpful.Anesthetic suppositories may be helpful.
OperativeOperative– Anal dilation.Anal dilation.– Lateral internal sphincterotomyLateral internal sphincterotomy– Fissurectomy and midline sphincterotomy.Fissurectomy and midline sphincterotomy.
Anal FistulaAnal Fistula
DefinitionDefinition
secondary to crohn’s, TB, CA of rectum or secondary to crohn’s, TB, CA of rectum or lymphogranuloma.lymphogranuloma.
S/SS/S– Watery or purulent discharge from the Watery or purulent discharge from the
external opening of fistulaexternal opening of fistula– Recurrent episode of pain.Recurrent episode of pain.– Pruritis.Pruritis.
ProctitisProctitis
CauseCause– NonspecificNonspecific– Ulcerative proctocolitisUlcerative proctocolitis– Crohn’s diseaseCrohn’s disease– InfectionInfection
Clostridium difficileClostridium difficileBacillary dysenteryBacillary dysenteryTB proctitisTB proctitisSyphilisSyphilisGonococcalGonococcal
ProctitisProctitisNonspecific proctitis Nonspecific proctitis
is an inflammatory condition affecting the is an inflammatory condition affecting the mucosa and, to a lesser extent, the mucosa and, to a lesser extent, the submucosa, confined to the terminal submucosa, confined to the terminal rectum and anal canal.rectum and anal canal. It is the most common variety.It is the most common variety.
Aetiology. Aetiology. This is unknown.This is unknown.The most acceptable hypothesis: It is a The most acceptable hypothesis: It is a limited form of ulcerative colitis (although limited form of ulcerative colitis (although actual ulceration is often not present).actual ulceration is often not present).
ProctitisProctitis
Clinical featuresClinical features
Middle-aged.Middle-aged.
Slight loss of blood in the motions.Slight loss of blood in the motions.
Diarrhoea Diarrhoea
On rectal examination, the mucosa feels warm On rectal examination, the mucosa feels warm and smooth. Often there is some blood on the and smooth. Often there is some blood on the examining finger.examining finger.
Proctoscopic and Sigmoidoscopic examination:Proctoscopic and Sigmoidoscopic examination:– Inflamed mucous membrane of the rectum, but Inflamed mucous membrane of the rectum, but
usually no ulceration. The mucosa above this level usually no ulceration. The mucosa above this level being quite normal.being quite normal.
ProctitisProctitis
TreatmentTreatment
Self-limiting.Self-limiting.
Sulphasalazine (Salazopyrin).Sulphasalazine (Salazopyrin).
Prednisolone retention enemas.Prednisolone retention enemas.
Severe cases Severe cases oral steroids. oral steroids.
Rarely Rarely surgical treatment (last resort) surgical treatment (last resort)
Pruritis aniPruritis ani
Definition: Perianal itching, particularly the Definition: Perianal itching, particularly the frequent and distressing one.frequent and distressing one.
EtiologyEtiology
SymptomsSymptoms
TreatmentTreatment
Rectal ProlapseRectal Prolapse
Definition: Eversion of whole thickness of Definition: Eversion of whole thickness of the lower part of rectum and anal canal.the lower part of rectum and anal canal.
TypesTypes
1.1. Partial prolapse.Partial prolapse.
2.2. Complete prolapse.Complete prolapse.
CauseCause
Predisposing factorsPredisposing factors
Differential diagnosisDifferential diagnosis
Rectal ProlapseRectal Prolapse
HistoryHistory
Age.Age.
Sex.Sex.
Symptoms.Symptoms.
ExaminationExamination
Rectal ProlapseRectal Prolapse
TreatmentTreatment
PartialPartial– InfantInfant– AdultAdult
Complete (Thiersch wire).Complete (Thiersch wire).
Pilonidal sinusPilonidal sinus
Definition: Sinus which contain tuft of Definition: Sinus which contain tuft of hairs, mainly in skin covering the sacrum hairs, mainly in skin covering the sacrum and coccyx but can occur between fingers, and coccyx but can occur between fingers, in hair dressers, and the umbilicus.in hair dressers, and the umbilicus.
EtiologyEtiology
SymptomsSymptoms
TreatmentTreatment– Acute abscessAcute abscess– Chronic abscessChronic abscess
Benign Anal TumorsBenign Anal Tumors
Villous AdenomaVillous Adenoma
Tubular PolypsTubular Polyps
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