1. Haemorrhoids

2. Essentials of diagnosis
Rectal bleeding, protrusion, discomfort
Mucoid discharge from rectum
Secondary anaemia
Characteristic findings on anal inspection and anuscopic examination

3. THE PROBLEM Nobody likes them: patients and doctors Very frequent
Major discomfort
Treated often by non-specialists
Well treated= good results

4. Sensitive area

5. DEFINITION
Normal structures of the rectal wall which are displaced from the original position
Normal histological structures
Plenty vascularization: both arterial (inferior haemorrhoidal artery) and venous lakes which may be distended.
Chrinic constipation + straining on defecation + increased anal tonus – favor the development of haemorrhoids.

6. Symptomatic classification
Grade 1 – bleeding
Grade 2 – prolaps with spontaneous reduction
Grade 3 – prolaps that needs digital replacement
Grade 4 – Prolaps - permanent
TRATAMENT – depending on symptoms

7. Anatomic classification

8. Symptoms Painless bleeding Pruritus Prolaps
Pain (asociated with a complication – thrombosis or inflamation)
Incontinence

9. BLEDDING PER RECTUM How to evaluate!!!
Small drops of blood on toilet paper
Clinical examination + rectal + rectoscopy
Blood dropping in the toilet
Rigid recto-sygnoidoscopy
Blood mixed with feces
Rigid recto-sygnoidoscopy + barium enema OR colonoscopy = complete examination of the colon
Dark blood
Complet examination of the colon

10. Massive OR Chronic May be massive and presents as an emergency
May be a cause of chronic anaemia
May explain
Severe iron deficiency anaemia
Ischaemic cardiac disease due to low levels of oxygen transporter

11. MALPRAXIS = patients life and your money
NEVER
NEVER treat haemorrhoidal disease without clinical and digital examination of the rectum
MALPRAXIS = patients life and your money

12. PRURITUS ANI Frequently associated with haemorrhoids
Minute incontinence with local irritation of the skin
Aggressive local cleaning may produce small lesions that will generate pruritus
Tags
Local edema

13. PAIN External thrombosed haemorrhoids Internal thrombosed haemorrhoids
Round blue lesions (perianal haematoma) with significant edema and very tender
Internal thrombosed haemorrhoids
Pain is less severe
Major pain in cases of strangulated prolaps of haemorrhoids

14.  EXAMINATION Speaking with the patient will create trust
Offer an intimate room 

15. RECTAL EXAMINATION Blind – use a hydro soluble gel
Forts evaluate visually the perianal region
Evaluate the tonicity of the sphincter in non contracting status and during contraction
Prostate
Content

16. RECTOSCOPY ANUSCOPY SYGMOIDOSCOPY

17. RECTOSCOPY + ANUSCOPY Masses that prolaps in the tube of the scope
Stigmata of recent bleeding

18. WHY COMPULSORY TO EVALUATE
Colonic cancer is frequently missed due to obvious haemorrhoidal disease
Main diagnosis is delayed for a long time – too late

19. CONSERVATIV TRATAMENT
Bleeding
Dietary suplements with fibers (larger volume + softer)
Increase vascular tonus
Ginko Biloba
Flavonoids (Detralex)

20. CONSERVATIV TRATAMENT
PRURITUS
Hot bath – decreasing muscular tonus
Fibers in food
Analgetic creams
Corticoids locally (supositories or cream) but no more then 7 days
Changed local hygiene

21. CONSERVATIV TRATAMENT
THROMBOSIS OF HAEMORRHOIDS
Surgical thrombectomy – first 48 hours
Analgetics
Dietary changes
Hot bath

22. Surgical treatment 1 – Milligan - Morgan

23. Surgical treatment 2 – Ferguson

24. Surgical treatment 3 – Stappler haemorrhoiedctomy

25. NEW TECHNIQUES

26. BANDING
Principles:
Elastic ligatures on the base of haemorrhoid followed by necrosis
Detachment of necrotic area
Scar formation + sclerosis will fix the mucosa

27. SCLEROTHERAPY Irritative substances (Almond oil + phenol)
Slerosis + fixation of mucosa
Injection only around vessels

28. ANAL DILATION Hypertony is a major cause of pain
Unde rgeneral anaesthesia
Make banding easier and better
Decreased the tonus of the sphincter – mechanism of hemorrhoid formation
Not in cases with low tonus

29. FOTOCOAGULATION Infrared radiation directly over the hemorrhoid
Therncauterisation followed by sclerosis
In stages

30. CRIOCOAGULATION and ELECTROCOAGULATION
Criotherapt forceps – rapid cooling at -36 degree
Similar effects with infrared thermocoagulation
Lesions will shrink
More efficient for large hemorrhoids

31. CO2 LASER Hemorrhoidectomy by vaporisation of tissue
Similar with surgical excision
Very expensive and difficult to use

32. Harmonic knife Ultrasonic energy
Very little effects on the tissue around the area treated
No smoke, low temperatures ( degrees)
Seals vessels and coagulates proteins

33. Harmonic knife No burned tissue (doesn’t coagulate via dessictaion)
Coagulates even large vessels
Low chances for postoperative bleeding

34. Ligation of haemorrhoidal artery HAL
New technoque
Ligation of feeding artery
Good results

35. COMPLICATIONS OF ALL METHODS
Stenosis
Tags
Recurencies
Fissure
Incontinence
Impactation with feces
Postop bleeding

36. RESULTS
Very good
Dependeing on the tpe of hemorrhoids and clnical signs
Rational choice of therapy
Better in the hands of a proffesional

37. FISSURA IN ANO ANAL FISSURE

38. General considerations
Denuded epithelium of the anal canal overlying the internal sphincter
Painful – highly sensitive area
Typically single ulcerations
Hypertrophic papilla – chronic inflammation
Sentinel pile

39. Diagnosis
3 ELEMENTS
Ulcer
Hypertrophic pappila
Sentinel tag

40. Clinical findings Symptoms and signs:
Painful bowel movement associated with bright red bleeding
Pain severe: after movement and sensation is described like burning
Constipation

41. Clinical examination With anaesthesia Rectal: Tag
Ulcer – in the middle
Pappila
Increased tonus
Sigmoidoscopy should be deffered

42. Differential diagnosis
Other ulcers:
Syphilis
Carcinoma
TBC
Granulomatous enetritis with ulcers
NOT TYPICAL
Biopsy
Association with haemorrhoids

43. TREATMENT Medical: Surgical: Softening of the stool
Topical cream with myorelaxant
Hot bath
Flavonoids
Surgical:
Lateral internal shpyncterotomy
Anal dilation

44. PROGNOSIS Very good if good care Tend to become chronic
The do not become malignant

45. ANORECTAL ABSCESS

46. ESSENTIALS OF DIAGNOSIS
Persistent throbbing rectal pain
External evidence of absecss
Systemic manifestations of infection

47. General considerations
Invasion of pararectal spaces by pathogenic microorganisms (mixed infection + frequent anaerobs)
Infection starts from an infected cript
Classification is anatomical according to the spaces invaded

48. Classification Perianal – bellow levator ani
Ischiorectal – ischiorectal fossa
Retrorectal
Submucous
Marginal – in the anal canal beneath the anoderm
Pelvirectal
Intermuscular

49. Clinical Findings The more superficial, the more painful
PAIN – related to sitting and walking
Infection: swelling, redness, induration, tenderness
Deep abscess – limited local signs + sepsis

50. Complications Spreading to adjacent spaces
Pelvic gangrene or necrotizing fasciitis when anaerobic infections spread without concern for anatomic bariers
Fistula formation

51. TREATMENT SURGICAL Incision and drainage
Do not wait for the abscess to point externally
Fistulotomy may come in discussion if a fistula is found (caution for the quality of the remnant sphincter)

52. ANORECTAL FISTULA

53. Essentials of diagnosis
Chronic purulent discharge
TRACT: palpable or probed will lead in the rectum

54. General considerations
At least 2 openings
Most fistulas originate in the anal cript
Subcutaneous
Submucoasal
Intramuscular
Submuscular
Anatomical
Anterior
Posterior
Single/complex
Horseshoe

55. Clinical Findings Symptoms and signs
Purulent drainage and discharge
Palpation - cordlike tract in relation with the spincter
Probe
Rectal examination + rectoscopy – the internal opening

56. Exploration Contrast fistulography MRI
Anatomy of the fistula for surgical excision
Mostly in complex fistulas

57. Differential diagnosis
Hidradenitis suppurativa
Pilonidal sinus
Granulomatous disease – Crohn
Infected lesions (comedomes, sebaceous cyst, foliculitis, bartholinitis)
Retrorectal dermooid tumor
Coloperineal fistula
Postraumatic sinuses or foreign body
Etc.

58. Complications Recurrent abscess formation Generalized sepsis
Carcinoma in a chronic untreated fistula is possible

59. Treatment SURGICAL Operations for fistula
Primary opening must be found end excised
Complete identification of the tract
The tract must be unroofed on the entire length – open wound
Careful construction of the wound to favor healing
Operations for fistula

60. Pilonidal disease

61. Essentials in diagnosis
Abscess or chronic discharges from a sinus in the sacrococcigeal area
Pain, tenderness, induration

62. General considerations
Drainig sinus or abscess
Underlying cyst containg granulomatous inflammation, fibrosis + tufts of hair
Congenital vs aquired
CAUSE: infection + irritation and trapping hair in deep tissue of the area

63. Clinical Findings Asymptomatic until becomes infected
Acute suppuration in sacrococcigean area
If drained spontaneously – sinus with intermittent discharge
Probe may pass in the sinus – in to the cyst

64. Complications Infection + multiple tracts Sepsis
Malignant degeneration - rarely

65. Treatment Acute abscess: Chronic disease: Drainage
Excision of all damaged tissue
Cystotomy to excision

66. Malignant tumors of the anal canal

67. Epidermoid carcinoma 75% of all malignancies of the area
Early: verucous, nodular lesion
Late: ulcerated, indurated, nodular nmass
Palpable inguinal nodes
May invade the rectum: false imprssion of rectal carcinoma
Lymphatic spread: like rectal + inguinal nodes

68. Treatment External radiation + concomitant chemotherapy
Radical surgery in case of failure

69. Malignant melanoma Horrible prognosis
Dark mass protruding from the anus
50% pigmented
Lymph node MTS early
Treatment - not clear advantage of any alternative

70. Bowen’s disease carcinoma in situ
Like all other places of skin
Plaque-like eczematoid lesion + pruritus
Biopsy-carcioma in situ + hyperkeratosis and giant cells
Therapy: local excision with safety margins

71. Basal cell carcinoma Ulcerating tumor (uncommon)
“Rodent ulcer” like every other place of skin exposed
Doesn’t spread distantly
Local excision

72. Paget’s disease Rare condition
Pale plaquelike condition with induration + nodular mass (not always)
Nodular mass= coloid carcinoma from glands or other skin appendages
Local excision (without mass)
Radical surgery + chemo + RT for coloid carcinoma