Case Scenarios32 year old male patient with 3 weeks h/o constipation, painful

defecation, passing pellet stools, minimal fresh bleeding P/R

Diagnosis

Rx

40 yr female with painless rectal bleed, constipation, pruritus ani

for 4 weeks. Previous h/o some injection into anal canal,

details unknown.

Dx, Rx

60 yr male with painless fresh bleeding p/r, altered bowel habit

for 3 months

Ddx

Invg, Rx

DISEASES OF ANAL CANAL

Topics: 1.Anorectal malformation

2.Pilonidal sinus

3.Fissure in ano

4.Haemorrhoids

5.Anorectal abscess(Peri-anal abscess)

6.Fistula in ano

ANATOMY4 cm length

Levator to anal verge

Mucosa

ectoderm: squamous

dentate line

endoderm: columnar

Muscle coat:

external sphincter

internal sphincter

Intersphincteric space

Anorectal ring

PILONIDAL SINUSSepsis in natal cleft area or level of 1st coccyx segment

Sites: natal cleft, web space hand, axilla, umbilicus

Aetiopathogenesis: acquired

occupational – hair stylist, jeep drivers

hairy men in 20-30 yrs

Loose hairs from back ---- penetrate pits in natal cleft

sepsis

Abscess cavity + tuft of hairs sinus tracts

C/F: recurrent infections, abscess, h/o I&Ds

Multiple sinus

Tender lump s/o abscess

Scars of prev surgery

Rx: 1.Conservative

- first mild attack

- Antiseptic wash

- hair removal

- Avoid prolonged driving (truckers)

2.Acute pilonidal infection

-Incision and drainage

-Antibiotics

-Hair removal

-Local hygiene

-Elective Surgery -- once infection controlled

a. Excision of cavity along with tracks, cavity heals by

secondary intention

b.Bascom technique: lateral incision to remove abscess

cavity, midline incision to remove pits.

c.Modified Limberg flap

FISSURE IN ANOAn anal fissure is a painful linear tear in the distal anal canal

Acute - < 6 weeks, mucosal tear

Chronic > 6 weeks, full thickness ulcer

Etiology: vicious cycle constipation passing

hard stool

painful mucosal tear straining at stool

defecation spasm of int. sphincter

FISSURE IN ANO

Site: posterior midline (98%) poorly perfused

hypertonicity of sphincter

anterior (2%)

C/F: painful defecation

passing pellet stools

bleeding P/R minimal

constipation

O/E: Acute: painful P/R

spasm of int. Sphincter

Chronic: sentinel pile

indurated ulcer posterior midline,

sphincter fibres seen, spasm +

Atypical fissure in ano - away from midline

Crohn’s, HIV, SCC anal canal

Treatment: 1.conservative break the cycle

Relieve shpincter spasm diltiazem cream

GTN cream

botulinum toxin injection

Relieve pain Sitz bath

Relieve constipation Laxatives

Diet - high fibre diet, 3 L fluids

Surgical: 1.Lateral internal sphincterotomy

2.Manual anal dilatation(MAD)

HAEMORRHOIDSDefn: dilated venous saccules in anal cushions

Anal cushions – highly vascular tissue near dentate line

Sup.haemorrhoidal artery – vein plexus

Etiology: Primary Secondary

pregnancy

pelvic tumour

CCF, constipation

rectal cancer

Anorectal varices

Types: 1.Internal – above dentate line

covered by mucosa

2.External perianal area

covered by skin

3.Intero-external prolapsing internal piles

Position: 3, 7, 11’O clock in lithotomy position

Haemorrhoids

Grading: 1st degree congested anal cushions

2nd degree prolapse, reduce spontaneously

3rd degree prolapse, manual reduction

4th degree permanent prolapsed piles

C/F: painless, bright red bleeding, ‘flash in pan’

pruritus ani

mucus discharge

constipation

Complications: anemia

thrombosis

Treatment

1. conservative: Gr I- dietary

2.Sclerotherapy Gr II -5% phenol in almond oil

STD

3.Banding Gr I, II

4.Haemorrhoidectomy Gr.III /IV

Cryosurgery, Stapled haemorrhoidectomy, Laser

ANORECTAL SEPSISDefn: pyogenic infection of anal glands in the inter-sphincteric

space, which later spreads to adjacent anatomical spaces.

Bacteriology: E.coli

Staph. aureus

Streptococcus, bacteroides

Risk factors: diabetic

Immunocompromised

Crohn’s

Low –socioeconomic strata

Poor local hygiene

TYPES1. Perianal follicle, sebaceous gland, haematoma

2. Submucous infected fissure, laceration

3. Ischiorectal anal gland, perianal abscess, FB

4. Pelvirectal pelvic abscess

TREATMENTC/F: severe pain, very tender swelling

‘do not wait for fluctuation’

Incision and drainage

Antibiotics

Ischiorectal abscess: diabetics

fever with chills

excruciating pain, sepsis

I&D by cruciate incision

FISTULA IN ANODefn: an abnormal communication between anal canal/rectum

and the perianal skin.

Etiopath: Majority arise from anal gland infection -------

abscess --- tracks into lumen and to exterior

Crohn’s disease, Ulc. Colitis

TB

Ca.rectum

Gut flora in anorectal abscess suggestive of underlying fistula

ANATOMICAL CLASSIFICATIONAccording to position and relation to the sphincters(internal &

external)

Superficial subcutaneous/submucous

Intersphincteric low anal fistula( 95% )

Trans-sphincteric

Suprasphincteric high fistula

Extrasphincteric

Goodsall’s law

FISTULA IN ANOC/F: h/o anorectal abscess I & D

Recurrent perianal infection

O/E: external opening of fistula

Scars of previous Sx

DRE – track felt as induration

Proctoscopy – internal opening sometimes seen

Most important – relation of track to the anal sphincters

Invg: Fistulogram

MRI – best

Endoanal US

TREATMENTPrinciples: Laying open the track, heal by granulation tissue

Low anal fistula- below the anorectal ring Fistulotomy

Fistulectomy

High fistula - lower track laid open, a seton is passed thru upper

track and tightened over 3-4 weeks

Track is gradually divided along with the sphincters

Crohn’s – antibiotics, anti-TNF - infliximab