1. Benign Anorectal Conditions
Ahmed Badrek-Amoudi FRCS

2. 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

3. 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%

4. 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

5. 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

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

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

19. 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

20. 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