Benign Anorectal Conditions Ahmed Badrek-Amoudi FRCS

Anorectal Anatomy Nerve Supply Arterial Supply Sympathetic: Superior hypogastric plexus Parasympathetic: S234 (nerviergentis Pudendal Nerve: Motor and sensory Arterial Supply Inferior rectal A middle rectal A Venous drainage Inferior rectal V middle rectal V 3 hemorrhoidal complexes L lateral R antero-lateral R posterolateral Anal canal Lymphatic drainage Above dentate: Inf. Mesenteric Below dentate: internal iliac Anal verge

Haemorrhoids Back Ground They are part of the normal anoderm cushions They are areas of vascular anastamosis in a supporting stroma of subepithelial smooth muscles. The contribute 15-20% of the normal resting pressure and feed vital sensory information . 3 main cushions are found L lateral R anterior R posterior But can be found anywhere in anus Prevalence is 4% Miss labelling by referring physicians and patients is common This combination is only in 19%

Haemorrhoids Pathogensis 3 main processes: 1. Increased venous pressure 2. Weakness in supporting fibromuscular stroma 3. Increased internal sphincter tone Risk Factors Abnormal haemorrhoids are dilated cushions of arteriovenous plexus with stretched suspesory fibromuscular stroma with prolapsed rectal mucosa Pathological Habitual Chronic diarrhea (IBD) Colon malignancy Portal hypertension Spinal cord injury Rectal surgery Episiotomy Anal intercourse Constipation and straining Low fibre high fat/spicy diet Prolonged sitting in toilet Pregnancy Aging Obesity Office work Family tendency

Haemorrhoids Classification: Degree of prolapse through anus Origin in relation to Dentate line 1st: bleed but no prolapse 2nd: spontaneous reduction 3rd: manual reduction 4th: not reducable Internal: above DL External: below DL Mixed

History ( Full history required) Haemorrhoids Clinical assessment Examination History ( Full history required) Local Inspect for: Lumps, note colour and reducability Fissures Fistulae Abscess Digital: Masses Character of blood and mucus Perform proctoscopy and sigmoidoscopy General abdominal examination Haemorrhoid directed: Pain acute/chronic/ cutaneous Lump acute/ sub-acute Prolapse define grade Bleeding fresh, post defecation Pruritis and mucus General GI: Change in bowel habit Mucus discharge Tenasmus/ back pain Weight loss Anorexia Other system inquiry

Haemorrhoids Investigations: Lab: CBC / Clotting profile/ Group and save Proctography: if rectal prolpse is suspected Colonoscopy: if higher colonic or sinister pathology is suspected The diagnosis of haemorrhoids is based on clinical assessment and proctoscopy Further investigations should be based on a clinical index of suspicion

Sepsis and abscess formation Incontinence Complications Ulceration Thrombosis Sepsis and abscess formation Incontinence Thrombosed internal haemorrhoids Thrombosed external haemorrhoids

Haemorrhoids Internal H. Treatment : Grade 1&2 Dietary modification: high fibre diet Stool softeners Bathing in warm water Topical creams NOT MUCH VALUE Conservative Measures Indicated in failed medical treatment and grades 3&4 injection sclerotherapy Rubber band ligation Laser photocoagulation Cryotherapy freezing Stapled haemorrhoidectomy Minimally invasive Indications: Failed other treatments Severely painful grade 3&4 Concurrent other anal conditions Patient preference Surgical

Haemorrhoids External H. Treatment : If presentation less than 72 hours: Enucleate under LA or GA Leave wound open to close by secondary intension Apply pressure dressing for 24 hours post op If more than 72 hours: Conservative measures

Perianal Fistula and Abscess Perianal abscess almost always arise from a fistulous tract. It is an infection of the soft tissue surrounding the anus. 5% Aetiology & Pathogenesis: 4-10 glands at dentate line. Infection of the cryptglandular epithelium resulting from obstruction of the glands. Ascending infection into the intersphincteric space and other potential spaces. Bacteria implicated: E.Coli., Enterococci, bacteroides Other causes: Crohn TB Carcinoma, Lymphoma and Leukaemia Trauma Inflammatory pelvic conditions (appendicitis) 60% 5% Ischiorectal 20% Intersphincteric suprasphincteric Trans-sphincteric extrasphincteric

Perianal Abscess Clinical presentation Perianal pain, discharge (pus) and fever Tender, fluctuant, erythematous subcutaneous lump Perianal Chills, fever, ischiorectal pain Indurated, erythematous mss, tender Ischio-rectal Rectal pain, chills and fever, discharge PR tender. Difficult to identify are. EUA needed Intersphincteric Supralevator

Peri-anal Fistula Clinical presentation Follow 40-60% of perianal abscess and cryptgland infections Presentation: External openings Purulent discharge Blood Perianal pain Godsalls law Anterior: drain straight Posterior: drain curved to anorectal midline Also associated with: IBD Malignancy TB/ Actinomycosis Diverticular disease

Perianal Abscess Management Aim: adequate drainage of abscess preservation of sphincter function * Preop: full lab evaluation *Always perform Examination under GA ( EUA) and obtain a biopsy. Treatment Abscess Incision and drainge de-roof cavity pack with gauze and iodine IV AB, sitz bath tid, laxitives and anlgesia F/U for fistula Perianal Ischio-rectal I&D through interspgincteric plane. Treat the underlying cause Intersphincteric Supralevator

Perianal fistula Managment Aim: Define anatomy Eliminate tract preservation of sphincter function * Preop: full lab evaluation *Always perform Examination under GA ( EUA) and obtain a biopsy. Treatment Fistula Fistulotomy vs fistulectomy Perianal Complex treatments using seton Trans/Extra/Supra sphincteric

Anal Fissure Linear tears in the anal mucosa exposing the internal sphincter 90% are posterior Caused mainly by trauma ( hard Stool). Followed by increased sphincter tone and ischemia. Other causes: IBD, Ca, Chronic infections

Anal Fissure Clinical Assessment Chronic Acute Pain mild to moderate More than 6 weeks Hypertrophied Int.sphincter Skin tag Granulation around the edge Sever acute pain Fresh blood spotting Clean linear tear.

Anal Fissure Treatment Surgical Lateral sphincterotomy Conservative High fibre diet Medical sphincterotomy: GTN Ca channel blockers Butulinum toxins

Pilonidal Sinus Pathogenesis: A sinus tract at natal cleft resulting from: Blockage of hair follicle Folliculitis Abscess followed by sinus formation. Hair trapping Foreign body reaction The sinus tract is cephald Associated with: Caucasians Hirsute Sedentary occupations Obese Poor hygeine

Presentation & Treatment Also found: umbilicus, finger webs, perianal area Incision and drainage Recurrence: 40% abscess Acute Wide local excision with primary closure or closure by secondary intension Recurrence: 8-15% Pain and discharge Chronic