1. Anal fissure (fissure in ano)
Is a longitudinal split (ulcer) in the anoderm of the distal anal canal
Location :90% midline posterior
AE/
post. Wall of rectum curved forward to join anal canal then turns sharply backward, during defecation ..pressure of hard fecal mass …post. anal tissue (unsupported by muscle )----tear.
Women ….anterior more (damaged pelvic floor)
recent …..ischemia
Other causes : posthaemorrhoidectomy..Infl. bowel dis., sexually trans. dis.

3. Pathology - indurated margins ,canoe shape
Acute anal fissure: deep tear ..skin.. from dentate line to anal verge
little inflam. Indurations edge
spasm of internal sphincter
Chronic anal fissure:
- indurated margins ,canoe shape
- skin tag …inf. edge (sentinel pile)
- hypertrophied anal papillae
- long standing ….internal sphincter …contracted by infiltration of fibrous tissue

5. Clinical features Symptoms: Age: adult life …not rare in children
Sex: male =female
Pain: sharp agonizing
Constipation
Bleeding slight bright streaks on the stool
Mucous Discharge and itching
On exam.:
Sentinel tag
Tightly closed puckered anus
Long. Ulcer male… post. (1% ant.) , female …post .(10% ant.)
Palpation only in chronic fissure with good local anesthesia ..button hole

6. Differential diagnosis
1- ca. of anal canal
2- multiple fissures or atypical sites ( infl.bowel.dis., sexually trans. Dis. Scratching, homosexual practice)
So any atypical ulcer or site need biopsy
3- tuberculous ulcer
4- proctalgia fugax: attacks of pain in rectum( segmental cramps of puborectalis muscle

7. Treatment Aim to obtain complete relaxation of inter. Sphincter
Conservative treat.:
Laxatives …stool soft and bulky.(celevac tab. Or senna tab.)
Anal dilatation
Nitric oxide :glyceryl trinitrate 0.2%
Diltiazim 2% twice daily.
Botulin toxin (paralysis of anal sphincter)

8. Tratment Operative measures:
Gentle dilatation of the sphincter( not used now)
Lateral anal sphincterotomy GA,LA lower 1/3 of inter.sphincter ….3 weeks
Dorsal fissurectomy and sphincterotomy
(healing time more 3 W, mucus discharge, incontinence)
Anal advancement flap: recently used

9. HaemorrhoidS(pile)
Dilated veins occurring in relation to the anus such H. may be internal ,external or interoexternal.
Internal H.:
Is displaced anal cushions due to a dilatation and enlagement of internal venous plexus .
A etiology:
1- hereditary: cong. weakness,abnormal large arterial supply

11. A etiology: 1- hereditary: cong
A etiology: hereditary: cong. weakness,abnormal large arterial supply 2- morphological: weight of column of blood 3- anatomical: loose submucous C.T., constricted by muscle 4- exacerbating factors: constipation, diarrhea

12. Pile may be symptomatic some other cond.
1- Ca. of rectum.
2- pregnancy: compression on sup. rectal vein
relaxing effect of progesterone
increase pelvic circulating volume
3- straining at micturation

13. Pathology Arranged in three group 3,7 and 11 o’clock
each pile divided to three parts:
1- pedicle at anorectal ring
2- internal H below anorectal ring and dentate line
3- external H bet. Dentate and anal verge

14. Clinical features symptoms:
1- bleeding: painless …1st degree
2- prolapse : on defecation but return….2nd degree or replaced manually ….3rd degree
Permanently prolapsed ….4th degree
3- discharge and pruritis
4- pain only in complicated case
5- anaemia: profuse bleeding

15. On exam.
Inspection: no finding in int .H….early
Diagnosis by proctoscopy
Sigmoidoscopy should be done

17. Complications Profuse haemorrhage Strangulation Thrombosis….ulceration
….supuration
..pylephlebitis(portal pyaemia)
…fibrosis
4. Gangrene

20. Treatment Non operative treatment: Symptomatic treatment:
Bulk laxative
Increase water and fiber diet
Avoid prolong sitting on toilet
Various compound preperations cream or ointment

21. Active treatment:
1- injection treatment: 1st degree, early 2nd
5 % phenol in almond oil
submucously
2- banding (Barron)
2nd degree
3- cryosurgery: application of liquid nitrogen
4- photocoagulation:

22. Operative treatment Haemorrhoidectomy:
Indications: 3rd and 4th degree, 2nd degree not cured by non operative treatment ,fibrosed H. , interoexternal H., profuse bleeding
Surgical excision of piles
- open
- close
- stapled haemorrhoidectomy (endostapling technique
Postoperative complication:
Early :pain..urine retension…reactionary haemorrhage
Late :secondary haemorrhage..anal stricture..anal
... incontinence ,submucous abscess .fissure

23. Management of complications
1 –profuse hemorrhage:
. Admission to the hospital
. Wide bore canula ,give fluid then blood
. Morphine
. operation
2- strangulation:
. Admission
. Analgesia
. AB
Warm bath, warm or cold pack with saline
surgery

24. External haemorrhoids
1- Thrombosed external H.( perianal haematoma)
small clot ……perianal C.T
back pressure on anal venule …straining, coughing, lifting a heavy weight
sudden sever painful swelling
on exam. Olive like bluish Tense tender swelling, haematoma
sequel:resolution,fibrosis(5 days self curing lesion
inflammation, burst (bleeding)
2- external associated with Int.H
3- dilatation of the veins of the anal verge