1. ANORECTAL DISEASES
Raid Yousef, MD
Trauma, Acute Care Surgery

2. 12-16 cm in length,
starting at about the sacral promontory extending to dentate line of anal canal
Anterior aspect of the upper cm is intraperitoneal with serosal surface.
Lower (majority of) rectum lies within extraperitoneal pelvis, with no serosa. 2

3. Three submucosal folds ( the valves of Houston )
Superior rectal valve
Middle rectal valve
Inferior rectal valve
Three submucosal folds ( the valves of Houston )

6. inferior mesenteric nodes Lymph from the upper and middle rectum flows in channels that parallel the arterial supply and is filtered by the inferior mesenteric nodes.
the internal iliac lymph nodes Lymph from the distal rectum flows into channels adjacent to the middle and inferior rectal arteries. These
channels drain to iliac nodes.

8. It is the terminal part of the large intestine.
It lies below the pelvic diaphragm level, in the ANAL
TRIANGLE OF PERINEUM, between the ischiorectal fossae.
The anatomical anal canal extends from the perineal skin to the linea dentata.
The surgical anal canal measures 4 to 5cm in length and
It begins at the anorectal junction ( anorectal ring ) and terminates at
the anal verge.
The anorectal ring This is the circular upper border of the puborectal muscle which is digitally palpable upon rectal ex. It lies approximately cm above the linea dentata. 16

11. The dentate or pectinate line:
marks the transition point between columnar rectal mucosa and squamous anoderm.
The anal transition zone:
The 1 to 2 cm of mucosa just proximal to the dentate line shares histologic characteristics of columnar, cuboidal, and squamous epithelium.
The columns of Morgagni:
The dentate line is surrounded by longitudinal mucosal folds, known as the columns of Morgagni, into which the anal crypts empty. These crypts are the source of cryptoglandular abscesses

13. The anal sphincter is comprised of three layers: Internal sphincter: continuance of the circular smooth muscle of the rectum, involuntary and contracted during rest, relaxes at defecation.
Intersphincteric space. Small anal glands are located between the internal and external sphincters and communicate with the anal crypts via anal ducts.
External sphincter: voluntary striated muscle, divided
in three layers that function as one unit.
These three layers are continuous cranially with the puborectal muscle and levator ani.

14. Above The dentate line
Below The dentate line
Arterial blood supply
Superior rectal artery
Middle rectal artery
inferior rectal artery
Venous drainage
Superior rectal vein (Portal)
middle & inferior rectal veins (systemic )
Lymphatic drainage
upper part of anal canal:
 Internal iliac nodes
Lower part of anal canal
into Superficial inguinal nodes.
Innervations
Autonomic
Somatic 22

15. Hemorrhoids muscle fibers that are located in the anal canal.
 cushions of submucosal tissue containing venules, arterioles, and smooth
muscle fibers that are located in the anal canal.
 left lateral, right anterior, and right posterior positions.
 Function: continence mechanism and aid in complete closure of the anal canal at rest.
 Because hemorrhoids are a normal part of anorectal anatomy, treatment is only indicated if they become symptomatic.
 Excessive straining, increased abdominal pressure, and hard stools increase
venous engorgement of the hemorrhoidal plexus and cause prolapse of
hemorrhoidal tissue.
 Bleeding, thrombosis, and symptomatic hemorrhoidal prolapse may result.

16. Hemorrhoids Distal to the dentate line and are covered with anoderm.
 External hemorrhoids
Distal to the dentate line and are covered with
anoderm.
thrombosis may cause significant pain
should not be ligated or excised without adequate
local anesthetic
A skin tag often persisting as the residua of a
thrombosed external hemorrhoid. Skin tags are
often confused with symptomatic hemorrhoids.
may cause itching and difficulty with hygiene if they
are large.
Treatment of external hemorrhoids and skin tags is
only indicated for symptomatic relief

17. Hemorrhoids
 Internal hemorrhoids
proximal to the dentate line and covered by insensate anorectal mucosa
may prolapse or bleed, but rarely become painful unless they develop thrombosis and necrosis(usually related to severe prolapse, incarceration, and/or strangulation(
graded according to the extent of prolapse : First degree 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.

18. Hemorrhoids Straddle the dentate line characteristics of both
 Combined internal and external hemorrhoids
Straddle the dentate line
characteristics of both
Hemorrhoidectomy is often required for large, symptomatic, combined
hemorrhoids.
 Postpartum hemorrhoids
result from straining which results in edema, thrombosis, and/or strangulation.
Hemorrhoidectomy is often the treatment of choice, especially if the patient has had chronic hemorrhoidal symptoms.

19. Hemorrhoids
 Portal hypertension
Was long thought to increase the risk of hemorrhoidal bleeding
Now understood that hemorrhoidal disease is no more common in patients with portal hypertension.
Rectal varices, however, may occur and may cause hemorrhage in these
patients
rectal varices are best treated by lowering portal venous pressure.
Rarely, suture ligation may be necessary if massive bleeding persists.
Surgical hemorrhoidectomy should be avoided : risk of massive, difficult- to-control variceal bleeding.

20. Hemorrhoids Treatment
 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.
pruritus often may improve with improved hygiene.

21. Hemorrhoids Treatment Rubber band ligation
Persistent bleeding from first-, second-,and selected third-degree
Severe pain will occur if the rubber band is placed at or distal to the dentate line
Other complications:urinary retention, infection, and bleeding

22. Hemorrhoids Treatment Infrared Photocoagulation
small first- and second-degree hemorrhoids
All three quadrants may be treated
during the same visit
Larger hemorrhoids and hemorrhoids with a significant amount of prolapse are not effectively treated with this technique

23. Hemorrhoids Treatment Sclerotherapy
first-, second-, and some third-degree hemorrhoids
One to 3 mL of a sclerosing solution (phenol in olive oil, sodium morrhuate, or quinine urea) is injected into the submucosa of each hemorrhoid
Few complications are associated with sclerotherapy, but infection and fibrosis have been reported

24. Hemorrhoids Treatment Excision of Thrombosed External Hemorrhoids
Acutely thrombosed external hemorrhoids generally cause intense pain and a palpable perianal mass during the first 24 to 72 hours after thrombosis
The thrombosis can be effectively treated with an elliptical excision performed in the office under local anesthesia
simple incision and drainage is rarely effective

25. Hemorrhoids Treatment Closed Submucosal Hemorrhoidectomy
 Operative Hemorrhoidectomy
Closed Submucosal Hemorrhoidectomy
Open Hemorrhoidectomy
Whitehead’s Hemorrhoidectomy
Procedure for Prolapse Hemorrhoids/Stapled Hemorrhoidectomy
Doppler-Guided Hemorrhoidal Artery Ligation

26. Complications of Hemorrhoidectomy
 Postoperative pain following excisional hemorrhoidectomy requires analgesia usually with oral narcotics. Nonsteroidal anti-inflammatory drugs, muscle relaxants, topical analgesics, and comfort measures, including sitz baths, are often useful as well
 Urinary retention is a common complication following hemorrhoidectomy and occurs in 10% to 50% of patients. The risk of urinary retention can be minimized by limiting intraoperative and perioperative intravenous fluids and by providing adequate analgesia
 Pain can also lead to fecal impaction. Risk of impaction may be decreased by preoperative enemas or a limited mechanical bowel preparation, liberal use of laxatives postoperatively, and adequate pain control.

27. Complications of Hemorrhoidectomy
 small amount of bleeding, especially with bowel movements, is to be expected
 massive hemorrhage can occur after hemorrhoidectomy. Bleeding may occur in the immediate postoperative period (often in the recovery room) as a result of inadequate ligation of the vascular pedicle. This type of hemorrhage mandates an urgent return to the operating room where suture ligation of the bleeding vessel will often solve the problem.
 Bleeding may also occur 7 to 10 days after hemorrhoidectomy when the necrotic mucosa overlying the vascular pedicle sloughs. some of these patients may be safely observed, others will require an exam under anesthesia to ligate the bleeding vessel or to oversew the wounds if no specific site of bleeding is identified.

28. Complications of Hemorrhoidectomy
 Infection is uncommon after hemorrhoidectomy. Severe pain, fever, and urinary retention may be early signs of infection. emergent examination
under anesthesia, drainage of abscess, and/or débridement of all necrotic
tissue are required.
 Long-term sequelae of hemorrhoidectomy
Incontinence
Stenosis
ectropion (Whitehead’s deformity)

29. Anal Fissure becomes a chronic fissure
 a tear in the anoderm distal to the dentate line
 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 contributes to development of a poorly healing wound that
becomes a chronic fissure
 vast majority posterior midline
 Ten percent to 15% occur in the anterior midline. Less than 1% of fissures occur off midline.

30. Anal Fissure Symptoms and Findings
 Characteristic symptoms:tearing pain with defecation and hematochezia
 sensation of intense and painful anal spasm lasting for several hours after a bowel movement.
 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
 acute fissure:superficial tear of the distal anoderm and almost always heals with medical management.

31. Anal Fissure
 Chronic fissures
develop ulceration and heaped-up edges with the white fibers of the internal anal sphincter visible at the base of the ulcer
often an associated external skin tag and/or a hypertrophied anal papilla internally
more challenging to treat and may
require surgery
A lateral location of a chronic anal fissure may be evidence of an underlying disease such as Crohn’s disease, HIV, syphilis, tuberculosis or leukemia

32. Anal Fissure Treatment
 focuses on breaking the cycle of pain, spasm, and ischemia 
First-line therapy to minimize anal trauma includes bulk agents, stool softeners, and warm sitz paths
 addition of 2% lidocaine jelly or other analgesic creams can provide additional symptomatic
 Nitroglycerin ointment has been used locally to improve blood flow but often causes severe
headaches
 topical calcium channel blockers (diltiazem) have also been
used to heal fissures and may have fewer side effects than topical nitrates
 Newer agents, such as arginine (a nitric oxide donor) and topical bethanechol (a muscarinic
agonist), have also been used to treat fissures
 Medical therapy is effective in most acute fissures, but will heal only approximately 50% of
chronic fissure

33. Anal Fissure Treatment
 Botulinum toxin (Botox) causes temporary muscle paralysis. Injection of botulinum toxin is used in some centers as an alternative to surgical sphincterotomy for chronic fissure. Although there are few long-term complications from the use of botulinum toxin, healing appears to be equivalent to other medical therapies.

34. Anal Fissure Treatment
 Surgical therapy
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
Approximately 30% of the internal sphincter fibers are divided laterally by using either an open or closed technique
Healing is achieved in more than 95% of patients using this technique and
most patients experience immediate pain relief
Recurrence occurs in less than 10% of patients, and the risk of incontinence (usually to flatus) ranges from 5% to 15%
Advancement flaps (VY) with or without sphincterotomy have also been reported to successfully treat chronic fissures.

35. lateral internal sphincterotomy

36. Advancement flaps (VY)

37. Cryptoglandular Abscess
 The majority of anorectal suppurative disease results from infections of the anal glands (cryptoglandular infection) found in the intersphincteric plane
 perianal abscess is the most common manifestation and appears as a painful swelling at the anal verge
 Spread through the external sphincter below the level of the puborectalis produces an ischiorectal abscess. These abscesses may become extremely large and may not be visible in the perianal region. Digital rectal exam will reveal a painful swelling laterally in the ischiorectal fossa.
 Intersphincteric abscesses occur in the intersphincteric space and are notoriously difficult to diagnose, often requiring an examination under anesthesia
 Pelvic and supralevator abscesses are uncommon and may result from extension of an intersphincteric or ischiorectal abscess upward or extension of an intraperitoneal abscess downward

38. Pathways of anorectal infection in
perianal spaces

39. Cryptoglandular Abscess
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 (either in the office or in the operating room)
 complex or atypical presentations may require imaging studies such as CT or MRI to fully delineate the anatomy of the abscess.

40. Cryptoglandular Abscess
Treatment
 Drainage as soon as the diagnosis is established
 If the diagnosis is in question, an examination and drainage under anesthesia
 Delayed or inadequate treatment may occasionally cause extensive and life-threatening suppuration with massive tissue necrosis and septicemia
 Antibiotics are only indicated if there is extensive overlying cellulitis or if the patient is immunocompromised, has diabetes mellitus, or has valvular heart disease

41. Perianal Abscess
 Most perianal abscesses can be drained under local anesthesia in the office, clinic, or emergency room
 Larger, more complicated abscesses may require drainage in the operating room
 A skin incision is created, and a disk of skin excised to prevent premature closure
 No packing is necessary, and sitz baths are started the next day

42. Ischiorectal Abscess
 causes diffuse swelling in the ischiorectal fossa that may involve one or both sides, forming a “horseshoe” abscess
 Simple ischiorectal abscesses are drained through an incision in the overlying skin
 Horseshoe abscesses require drainage of the deep postanal space and often require counterincisions over one or both ischiorectal spaces

43. Intersphincteric Abscess
 difficult to diagnose because they produce little swelling and few perianal signs
 Pain is typically described as being deep and “up inside” the anal area and
is usually exacerbated by coughing or sneezing
 The pain is so intense that it usually precludes a digital rectal examination
 The diagnosis is made based on a high index of suspicion and usually requires an examination under anesthesia
 can be drained through a limited, usually posterior, internal
sphincterotomy

44. Supralevator Abscess  uncommon and can be difficult to diagnose
 can mimic intra-abdominal conditions, rectal examination may reveal an indurated, bulging mass above the anorectal ring.
 If a supralevator abscess arises from the upward extension of an ischiorectal abscess, it should be drained through the ischiorectal fossa. Drainage of this type of abscess through the rectum may result in an extrasphincteric fistula
 If the abscess is secondary to intra-abdominal disease, the primary process requires treatment and the abscess is drained via the most direct route(transabdominally, rectally, or through the ischiorectal fossa)

45. Summary
Proper ano-rectal physical exam is of upmost importance to reach the right diagnosis and to implement the proper treatment

46. Questions