Lec 6 Anal Diseases PDF

Lec. 6: ANORECTAL DISEASES Presented by Dr. Moamen Shalkamy Lecturer of colorectal & laparoscopic surgery BACKGROUND Any patient with anal/perianal symptoms requires a careful history and physical, including a digital rectal examination....

Lec. 6: ANORECTAL DISEASES Presented by Dr. Moamen Shalkamy Lecturer of colorectal & laparoscopic surgery BACKGROUND Any patient with anal/perianal symptoms requires a careful history and physical, including a digital rectal examination. Other studies such as defecography, manometry, CT scan, MRI, contrast enema, endoscopy, endoanal ultrasound, or exam under anesthesia may be required to arrive at an accurate diagnosis. The primitive gut is derived from the endoderm and divided into three segments: foregut, midgut, and hindgut. The hindgut develops into the distal transverse colon, descending colon, rectum, and proximal anus, all of which receive their blood supply from the inferior mesenteric artery and portal circulation. The distal anal canal is derived from ectoderm , proctodium, and receives its blood supply from the internal pudendal artery, systematic circulation The dentate line divides the proximal endodermal hindgut from the ectodermal distal anal canal. Arterial supply of the rectum and anal canal The lining membrane of the anal canal 1|Page  SURGICAL ANATOMY OF THE ANAL 1.Internal sphincter It is the continuation of the circular muscle layer of the rectum It surround the upper ¾ of the anal canal It is involuntary sphincter , it is innervated by the autonomic nervous system, it receives intrinsic non-adrenergic and non-cholinergic (NANC) fibres, Surgical importance: it shows a spasm in any painful anal condition , eg anal fissure division of the anal sphincter in such case relieve spasm ,improve healing og the anal fissure with no effect on anal continence. 2.External sphincter Being somatic voluntary muscle Surround the whole length of the anal canal lies outsides the internal anal sphincter It is innervated by the pudendal nerve. traditionally it has been subdivided into deep, superficial and subcutaneous portions Surgical importance : surgical division of the external sphincter up to the deep part in case of trauma or during surgery for perianal fistula produce anal incontinence. 3.Anorectal ring The anorectal ring marks the junction between the rectum and the anal canal. It is formed by the joining of the puborectalis muscle , the deep external sphincter, conjoined longitudinal muscle and the highest part of the internal sphincter. The anorectal ring can be clearly felt digitally, especially on its posterior and lateral aspects. 2|Page  HEMORRHOIDS Hemorrhoids are cushions of submucosal tissue containing venules, arterioles, and smooth muscle fibers that are normally located in the anal canal. Three hemorrhoidal cushions are Classically occur in the 3, 7 and 11 o’clock positions with the patient in the lithotomy position. Increase venous engorgement of the hemorrhoidal plexus and cause prolapse of hemorrhoidal tissue. Aetiology Venous engorgement of the hemorrhoidal plexus could occur due to : a) Excessive straining as in constipation , hard stool and pregnancy b) increased abdominal pressure c) portal hypertension d) low rectal cancer Clinical Findings 1. Symptoms: bright-red, painless bleeding usually with defecation mucous discharge prolapse Anal pain in case of prolapse or thrombosis 2. Signs External hemorrhoids Internal hemorrhoids located distal to the dentate line and are located proximal to the dentate line and covered with anoderm. covered by insensate anorectal mucosa Because the anoderm is richly Internal hemorrhoids may prolapse or innervated, external hemorrhoid may bleed, but rarely become painful unless cause significant pain. they develop thrombosis and necrosis Internal hemorrhoids are graded according to the extent of prolapse. Firstdegree hemorrhoids bulge into the anal canal and may prolapse beyond the dentate line on straining. Second-degree hemorrhoids prolapse through the anus but reduce spontaneously. Third-degree hemorrhoids prolapse through the anal canal and require manual reduction. Fourth-degree hemorrhoids prolapse but cannot be reduced and are at risk for strangulation. 3|Page  third degree haemorrhoids carcinoma of the rectum with piles Complications of haemorrhoids 1. Strangulation and thrombosis 4. Portal pyaemia 2. Ulceration 5. Fibrosis 3. Gangrene Investigation: Diagnosis is mainly clinical except the 1st degree internal piles Proctoscopy , sigmoidoscopy and colonoscopy ✓ Visualizes the internal hemorrhoids. ✓ it is important to exclude cancer rectum ✓ to exclude another causes of bleeding per rectum CBCs of diagnosis of anaemia Coagulation profile to exclude general causes of bleeding Treatment a) Medical Therapy: Bleeding from first- and second-degree hemorrhoids often improves with the addition of dietary fiber, stool softeners, increased fluid intake, and avoidance of straining and hemostatic drugs b) Rubber Band Ligation: Persistent bleeding from first-, second-, and selected third degree hemorrhoids may be treated by rubber band ligation. c) Infrared Photocoagulation: Infrared photocoagulation is an office treatment for small first- and second-degree hemorrhoids. The instrument is applied to the apex of each hemorrhoid to coagulate the underlying plexus d) Sclerotherapy: The injection of bleeding internal hemorrhoids with sclerosing agents is another effective office technique for treatment of first-, second-degree hemorrhoids. 4|Page e) Operative Hemorrhoidectomy: A number of surgical procedures have been described for elective resection of symptomatic hemorrhoids. All are based on decreasing blood flow to the hemorrhoidal plexuses and excising redundant anoderm and mucosa. 1. Open hemorrhoidectomy: after excision the wound left opened 2. Closed hemorrhoidectomy : after excision the wound is closed 3. Stappled hemorrhoidectomy: using circular stapler Rubber band ligation of internal hemorroid Complications of haemorrhoidectomy 1. Early: Pain , Acute retention of urine and haemorrhage 2. Late : Anal stricture , Anal fissure, anal stenosis and anal Incontinence ANAL FISSURE Anal fissure is a tear in the anoderm distal to the dentate line. The pathophysiology Anal fissure is thought to be related to trauma from either the passage of hard stool or prolonged diarrhea. A tear in the anoderm causes spasm of the internal anal sphincter, which results in pain, increased tearing, and decreased blood supply to the anoderm. This cycle of pain, spasm, and ischemia contributes to development of a poorly healing wound that becomes a chronic fissure. The vast majority of anal fissures occur in the posterior midline. Ten percent to 15% occur in the anterior midline. Less than 1% of fissures occur lateral location. A lateral location of a chronic anal fissure may be evidence of an underlying disease such as Crohn’s disease, HIV, syphilis, tuberculosis. 5|Page Symptoms and Findings. Anal fissure is extremely common. Characteristic symptoms include tearing pain with defecation and hematochezia (usually described as blood on the toilet paper). Patients may also complain of a sensation of intense and painful anal spasm lasting for several hours after a bowel movement. On physical examination, the fissure can often be seen in the anoderm by gently separating the buttocks. Patients are often too tender to tolerate digital rectal examination, anoscopy, or proctoscopy. Types of anal fissure: 1.Acute fissure 2.Chronic fissures develop ulceration and heaped-up edges is a superficial tear of the distal anoderm with the white fibers of the internal anal and usually heals with medical sphincter visible at the base of the ulcer. management There often is an associated external skin tag and/or a hypertrophied anal papilla internally Treatment Therapy focuses on breaking the cycle of pain, spasm, and ischemia thought to be responsible for development of fissure in ano. 1.Medical therapy It is effective in most acute fissures, but will heal only approximately 50% of chronic fissures. Minimize anal trauma includes bulk agents, stool softeners, and warm sitz baths. The addition of 2% lidocaine jelly or other analgesic creams can provide additional symptomatic relief. Nitroglycerin ointment has been used locally to improve blood flow but may causes a headaches. Both oral and topical calcium channel blockers (diltiazem and nifedipine) Newer agents, such as arginine (a nitric oxide donor) and topical bethanechol (a muscarinic agonist), have also been used to treat fissures 2.Botulinum toxin (Botox) Injection of botulinum toxin causes temporary muscle paralysis by preventing acetylcholine release from presynaptic nerve terminals. 3.Surgical therapy It has traditionally been recommended for chronic fissures that have failed medical therapy, Lateral internal sphincterotomy is the procedure of choice. The aim of this procedure is to decrease spasm of the internal sphincter by dividing a portion of the muscle. Approximately 30% of the internal sphincter fibers 6|Page  ANORECTAL SEPSIS Relevant Anatomy The majority of anorectal suppuration results from infections of the anal glands (cryptoglandular infection) found in the intersphincteric plane. Their ducts traverse the internal sphincter and empty into the anal crypts at the level of the dentate line. Infection of an anal gland results in the formation of an abscess that enlarges and spreads along one of several planes in the perianal and perirectal spaces. 1. The perianal space ( perianal abscess ) surrounds the anus and laterally becomes continuous with the fat of the buttocks. 2. The intersphincteric space ( intersphincteric abecess) separates the internal and external anal sphincters. It is continuous with the perianal space distally and extends cephalad into the rectal wall. 3. The ischiorectal space (ischiorectal fossa abscess) is located lateral The two ischiorectal spaces connect posteriorly above the anococcygeal ligament but below the levator ani muscle, forming the deep postanal space. 4. The supralevator spaces lie above the levator ani on either side of the rectum and communicate posteriorly. Diagnosis. Severe anal pain is the most common presenting complaint. A palpable mass is often detected by inspection of the perianal area or by digital rectal examination. Occasionally, patients will present with fever, urinary retention, or lifethreatening sepsis. The diagnosis of a perianal or ischiorectal abscess can usually be made with physical exam alone. However, complex or atypical presentations may require imaging studies such as CT or MRI to fully delineate the anatomy of the abscess. Treatment Anorectal abscesses should be treated by drainage as soon as the diagnosis is established, usually under general anasthesia Delayed or inadequate treatment may occasionally cause extensive and life-threatening suppuration with massive tissue necrosis and septicemia. Antibiotics are not essential except for certain situations as diabetic, immunocompromized patients, or presence of extensive cellulitis.. 7|Page  Anatomy of the perianal spaces Pathway of anorectal infection in perianal space PERIANAL FISTULA A fistula-in-ano is an abnormal hollow tract or cavity that is lined with granulation tissue and that connects a primary opening inside the anal canal to a secondary opening in the perianal skin It should be differentiated from the following processes, which do not communicate with the anal canal: o Hidradenitis suppurativa o Infected inclusion cysts o Pilonidal disease o Bartholin gland abscess in females 8|Page Classifications Standard classification: according to position of internal opening and course of the tract to the anorectal ring 1. Low fistula: below the anorectal ring. 2. Hiqh fistula: above the anorectal ring. The Goodsall rule The Goodsall rule can help anticipate the anatomy of a fistula-in-ano. This rule states that fistulas with an external opening anterior to a plane passing transversely through the center of the anus will follow a straight radial course to the dentate line. Fistulas with their openings posterior to this line will follow a curved course to the posterior midline. Exceptions to this rule are external openings lying more than 3 cm from the anal verge The Goodsall rule Parks classification system 1. Inter sphincteric fistula: 45% tracks between the internal anal sphincter and the external anal sphincter in the intersphincteric space 2. Trans sphincteric fistula 40% have a primary track that crosses both internal and external sphincters leaves the intersphincteric space over the top of the 3. Supra sphincteric fistula: puborectalis and penetrates the levator muscle before tracking down to the skin. 4. Extra sphincteric fistula: tracks outside of the external anal sphincter and penetrates the levator muscle into the rectum. 9|Page  Parks classification system Etiology In the vast majority of cases, fistula-in-ano is caused by a previous anorectal abscess After surgical or spontaneous drainage in the perianal skin, a granulation tissue–lined tract is occasionally left behind, causing recurrent symptoms. Multiple series have shown that formation of a fistula tract after anorectal abscess occurs in 7-40% of cases Other fistulas develop secondary to: ✓ trauma (eg, rectal foreign bodies), ✓ Crohn disease, ✓ anal fissures, ✓ carcinoma, ✓ radiation therapy, ✓ actinomycoses History Patients often provide a reliable history of previous pain, swelling, and spontaneous or planned surgical drainage of an anorectal abscess. symptoms of fistula-in-ano, include the following : 1. Perianal discharge 2. Pain 3. Swelling 4. Bleeding 5. Skin excoriation 6. External opening 10 | P a g e  Physical Examination Physical findings are the mainstay of diagnosis: a) External opening b) Digital rectal examination (DRE) may reveal a fibrous tract or cord beneath the skin c) the relationship between the anorectal ring and the position of the tract and internal opening d) The sphincter tone and voluntary squeeze pressures should be assessed before any surgical intervention to determine whether preoperative manometry is indicated. probing of the fistula tract in the office, and this should be avoided Imaging Studies 1. Fistulography 2. Endoanal or endorectal ultrasonography 3. Magnetic resonance imaging 4. Anal Manometry Treatment 1.Fistulotomy The laying-open technique (fistulotomy) is useful for 85-95% of primary fistulas ( intersphincteric, and low transsphincteric Patients with good anal tone General principles: ✓ The fistulous track is laid open. ✓ The track is curetted. ✓ Trimming of the edges, the wound is left open to heal by secondary intention. 2.Seton Placement This technique is useful in patients with the following conditions : 1. Complex fistulas (ie, high transsphincteric, suprasphincteric, extrasphincteric) or multiple fistulas 2. Recurrent fistulas after previous fistulotomy 3. Poor preoperative sphincter pressures 4. Patients with Crohn disease or patients who are immunosuppressed Setons can be made from large silk suture, silastic vessel markers, or rubber bands Types of setons: cutting ( tight seton) or draining ( lose seton ) a) Cutting tight seton : gradually cut the sphincter over long period to avoid incontinence b) Draining lose seton : for drainage of septic focus leaving it heal spontaneously then removed 11 | P a g e 3.LIFT Procedure Ligation of the intersphincteric fistula tract (LIFT) is a sphincter-sparing procedure for complex transsphincteric fistulas 4.Fistula Laser Closure (FiLaC™) The primary closure of the track is achieved using laser energy emitted by a radial fiber connected to a diode laser The energy causes shrinkage of the tissue around the fiber and closure of the track 5.Diversion colostomy In rare cases, the creation of a diverting stoma may be indicated to facilitate the treatment of a complex persistent fistula-in-ano The most common indications include, patients with perineal necrotizing fasciitis, severe anorectal Crohn disease, reoperative and radiation-induced fistulas Complications of surgery 1. Early postoperative complications may include the following: a) Urinary retention b) Bleeding 2. Delayed postoperative complications may include the following: a) Recurrence b) Incontinence (stool) c) Anal stenosis TUMORS OF THE ANAL CANAL CLASSIFICATION 1. Anal Canal Tumors 2. Anal Margin Tumors (tumors of anal verge and perianal skin) a) Noninvasive : Anal intraepithelial neoplasia (AIN) is considered a a) squamous cell carcinoma (SCC) as well precursor to anal Squamous cell as its precursor AIN carcinoma (SCC) b) verrucous carcinoma ( giant condyloma) b) Invasive carcinomas are classified as c) basal cell carcinoma Squamous cell carcinoma (SCC), below d) Paget's disease the dentate line e) Melanoma Adenocarcinoma, above the dentate line (mucinous adenocarcinoma, small cell carcinoma, and undifferentiated carcinoma) 12 | P a g e  AETIOLOGY HPV ( human papilloma virus infection, sexually transmitted disease ) is the most important causative factor in the development of anal SCC Immunosuppression & HIV cigarette smoking SPREAD a) Local spread: − upwards to the rectum or down wards to the skin or infilterate anal sphincter or posterior vaginal wall b) blood spread: − Above the dentate line , to the liver through the portal circulation − Below the dentate line to liver , lung , bone or brain through the systemic circulation. c) Lymphatic spread: − Above the dentate line ) , inferior mesenteric and para-aortic LNs. − Below the dentate line ) inguinal LNs. CLINICAL PRESENTATION Bleeding per rectum, Lump Pain especially with defecation. DPR examination : tumor is felt or indurated ulcer that bleeds easily Palpable lnguinal LNs DIAGNOSIS Biopsy for pathological diagnosis of anal canal lesion MSCT or MRI abdomen and pelvis for staging Full Colonoscopy : exclude any lesion in the colon Squamous cell carcinoma of the anus Malignant melanoma of the anal canal 13 | P a g e TREATMENT Carcinoma of the anal margin Carcinoma of the anal canal Wide local excision with 1 cm safety Abdominoperineal resection of the anal margin, canal and the rectum with a terminal If safety margin not achieved , colostomy. abdominoperineal resection Combination chemotherapy is followed if there are metastatic LNs: inguinal by radiotherapy; the patient is block lymph node dissection. examined after 4-6 weeks if there is evidence of residual tumor, abdominoperineal resection is performed PILONIDAL SINUS 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. Clinical features The condition is seen much more frequently in men than in women, usually after puberty and before the fourth decade of life, and common on drivers with prolonged setting It is characteristically seen in dark-haired individuals rather than those with softer blond hair. Patients complain of intermittent pain, swelling and discharge at the base of the spine, but little in the way of constitutional symptoms. There is often a history of repeated abscesses that have burst spontaneously or which have been incised, usually away from the midline. The primary sinus may have one or many openings, all of which are strictly in the midline between the level of the sacrococcygeal joint and the tip of the coccyx. 14 | P a g e Treatment Treatment of an acute exacerbation (abscess) Conservative treatment: rest, baths, local antiseptic dressings and the administration of a broad-spectrum antibiotic, Abscess drainage: abscess should be drained through a small longitudinal incision made over the abscess and away from the midline, with thorough curettage of granulation tissue and hair. This procedure may or may not be associated with complete resolution. Surgical treatment of chronic pilonidal disease A number of procedures have been proposed to treat a chronic pilonidal sinus. 1. Open technique: ✓ excision of the tract without primary closure ✓ unroofing ( lay open) the tract, curetting the base, and marsupializing the wound, also no primary closure ✓ The wound must then be kept clean and free of hair until healing is complete (often requiring weekly office visits for wound care). 2. Closed technique : Excision of all tract then closure of the wound with a Z-plasty, advancement flap, or rotational flap,( procedures designed to avoid a midline wound to avoid recurrence) FECAL INCONTINENCE Aetiology Damaqe to the anal sphincter mechanism due to: a. Obstetrical trauma causing complete perineal tear. b. Surgical trauma: e.g. during surgery for a high anal fistula. c. Accidental trauma Complete rectal prolapse: The prolasping rectum stretches the anal sphincters damaging them Neuroloqical diseases: Trauma or tumors affecting the second, third, fourth sacral nerves. Diabetic neuropathies. ldiopathic fecal incontinence: Loss of storage capacity in the rectum: After rectal resection in case of rectal canccer Diarrhea: Solid stool is easier to retain in the rectum than is loose stool, so the loose stools of diarrhea can cause or worsen fecal incontinence 15 | P a g e ASSESSMENT ✓ History Degree of incontinence (incontinence to flatus only, to flatus and fluid stools, or to solid stools as well). History of trauma, surgery or difficult labor ✓ Examination Rectal prolapse. Sphincter contraction. Neurological assessment. lnvestigations Manometry: to detect rectal functions, length and strength of anal sphincters Electromyography: maps out the sphincter to detect silent areas. Defecography: to assess the anorectal angle. Transanal U/S: to localize the site of sphincteric damage, Treatment Conservative treatment :(In mild cases) Surgery Constipating agent and low fiber diet to Sphincteroplasty: sphincter injury repair thicken the stools. Surgical correction of rectal prolapse Anal sphincters and pelvic floor Colostomy (bowel diversion) exercises. Evacuating the bowel completely with glycerin suppositories in the morning to avoid soiling later in the day. Biofeedback and Bowel training. Sacral nerve stimulation 16 | P a g e