Acute Anorectal Conditions

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Acute Ano-rectal Conditions
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Anal Rectal Diseases

• Anal Abscess
• Anal Cancer
• Anal Fissure
• Anal Warts
• Cancer of the Anus
• Cancer of the Rectum
• Condyloma
• Cryptitis
• Enlarged Papillae
• Fecal Incontinence
• Fissure
• Fistula-in-ano

HemorrhoidsLevator Syndrome Pilonidal
Cyst Polyps Procidentia Proctalgia
Fugax Proctitis Pruritus Ani Rectal
Prolapse Rectocele Warts Venereal
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History

• Age
• Hemorrhoids-
• common all ages but are uncommon below the age
  of 20 years.
• Perianal haematomata-
• occurs at all ages
• Fissure-in-ano-(acute)
• quite common in children
• Anorectal abscess-
• common between the ages of 20 and 50 years.
• Pilonidal sinus-
• rare before puberty and in people over 40 years.

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History

• Sex
• Hemorrhoids-
• common in both sexs
• Perianal haematomata-
• occurs at all ages
• Fissure-in-ano-
• common in men
• Anorectal abscess-
• more common in men
• Pilonidal sinus-
• more common in men
• Prolapse of rectum-
• more common in women

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History

• Principal symptoms of rectal and anal conditions
• Bleeding
• Pain
• Tenesmus
• Change in bowel habit
• Change in the stool
• Discharge
• pruritis

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History - Bleeding

• Can be fresh or altered
• Example of altered is melaena
• Black tarry stool
• Recognizable blood may appear in four ways
• Mixed with faeces
• On the surface of the faeces
• Separate from the faeces after/unrelated to
  defaecation
• On the toilet paper after cleaning

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History - Bleeding

• Diagnosis of anal conditions which present with
  rectal bleeding
• Bleeding but no pain
• Blood mixed with stool ca of colon
• Blood streaked on stool ca of rectum
• Blood after defaecation hemorrhoids
• Blood and mucus colitis
• Bleeding pain fissure or carcinoma of anal
  canal
• The most common causes of rectal bleeding in
  patients who visit primary care physicians are
  hemorrhoids, fissures and polyps.

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History Anal pain

• careful history focusing on the nature of the
  pain and its relationship to defaecation
• The pattern of pain helps differentiate anal
  fissure from hemorrhoids and other conditions.
  (hemorrhoids and rectal cancer are usually not
  painful)
• Anorectal pain that begins gradually and becomes
  excruciating over a few days with localized are
  of tenderness is more likely to be
• abscess.
• A nagging, aching discomfort made worse by
  defecation could be due to
• piles.
• An occasional, severe, cramp-like pain deep in
  the anal canal, that often occur at night,
  lasting about half an hour
• proctalgia fugax. Proctalgia fugax pain is
  excruciating and may be accompanied by sweating,
  pallor and tachycardia. Patients experience
  urgency to defecate, yet pass no stool.
• A knife-like pain when you have your bowels open,
  and which may last for 1015 minutes afterwards.
  often described like 'passing glass'. In addition
  to the pain, some bright red blood on the toilet
  paper is noticed.
• Anal fissure.

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History Anal pain

• Diagnosis of anal conditions which present with
  pain
• Pain alone
• Fissure ( pain after defaction)
• Proctalgia fugax (pain spontaneously at night)
• Anorectal abscess
• Pain with bleeding
• Fissure
• Pain with a lump
• Perianal haematoma
• Anorectal abscess
• Pain, lump and bleeding
• Prolapsed haemorrhoids/rectum
• Carcinoma of the anal canal

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Anorectal examination

• One of the most important examinations in a
  patient with abdominal disease.
• Still its the least popular segment of the entire
  physical examination.
• Should not be omitted from your examination,
  especially in middle-aged and older patient, why?
• risks missing an asymptomatic carcinooma
• Can be done in numerous positions
• Left Lateral (Sims) position. The usual position
  when the patient is in bed. Turn patient on to
  left side with pelvis vertical. Ask patients to
  draw knees up to chest with buttocks on the side
  of the couch
• The Knee-elbow position. Patient kneeling on
  couch, resting on elbows, of particular use when
  palpating the prostate and seminal
• The Dorsal Position. This position with the
  patient lying on the back with right leg flexed
  is useful when the patient is in severe pain, and
  movement is contra-indicated. Enables assessment
  of rectovesical pouch in abdominal emergencies.
• Lithotomy. best position for examination but not
  always available.

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Anorectal examination

• Things never to be forgotten
• Explain necessity of procedure and reassure the
  patient
• Explain the procedure
• Tell the patient that is usually uncomfortable
  but not painfull Get informed consent
• Ensure adequate privacy
• Obtain services of chaperone if appropriate
• Expose the patient from waist to knee and explain
  the position of examination.
• Equipment plastic glove lubricating jelly
  good light

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Anorectal examination

• External inspection
• Piles.
• Skin tags (normal, Crohn's, hemorhoids).
• Rectal prolapse.
• Anal fissure.
• Fistula.
• Anal warts.
• Carcinoma.
• Signs of incontinence, diarrhea.
• External inspection (straining)
• Ask pt. to strain.
• Rectal prolapse upon straining.
• Hemorrhoid prolapse.
• Incontinence.
• Ask if straining is painful

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Anorectal examination

• palpation
• Lubricate index finger.
• Insert finger slowly, assessing external
  sphincter tone as enter.
• Male palpate prostate anterior of rectum
  Hard nodule (prostate cancer). Tender
  (prostatitis).
• Female palpate cervix anterior of rectum
  Mass in pouch of Douglas.
• Rotate finger, palpating along left, posterior,
  right walls.
• Withdraw finger.
• Wipe lubricant off pt.
• Ask if was significant pain during examination. 

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Anorectal examination

• Inspect withdrawn fingertip for
• Blood, melaena
• Stool color
• Pus
• Mucous.
• Other examination would be systemically preformed
  and depends on the case you have e.g swelling
  such as anorectal abscess or ulcers.

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Acute Ano-rectal Conditions
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ANORECTAL ABSCESS

• An anorectal abscess is a collection of pus in
  the anal or rectal region
• CausesInfection of an anal fissure (cleft or
  slit), sexually transmitted infections, and
  blocked anal glands are common causes of
  anorectal abscesses
• Abscesses may occur in an area that is easily
  accessible for drainage, or higher in the rectum.
• Deep rectal abscesses may be caused by intestinal
  disorders such as Crohn's disease or
  diverticulitis.

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ANORECTAL ABSCESS

• High risk groups include diabetics,
  immunocompromised patients, people who engage in
  receptive anal sex, and patients with
  inflammatory bowel disease.
• The male to female ratio is approx. 21
• The most common organisms
• E.coli (60)
• Staph. aureus (23)
• Common sites of anorectal abscesses

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ANORECTAL ABSCESS

• Symptoms and signs
• Pain ( the most common symptom)
• Swelling (95 of patients)
• Discharge (12 of patients)
• Fever(18 of patients )
• Constipation (may occur)
• Rigors ,sweating and tachycardia
• Complications systemic infection, ,recurrence ,
  scarring and anal fistula formation
• TESTS Rectal examination , Proctosigmoidoscopy
• Treatment
• Urgent incision and drainage( the
  treatment of choice)
• Antibiotics

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Rectal prolapse

• Rectal prolapse is the abnormal movement of the
  rectal mucosa down to or through the anal
  opening.

Mucosal prolapse
Complete rectal prolapse
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Rectal prolapse

• Mucosal prolapse is more often seen in children
  below 3 yrs of age following an attack of
  diarrhoea or whooping cough , and if it occurs in
  adult is usually associated with haemrrhoids.
• Complete rectal prolapse is seen more commonly in
  elderly women who have a habit of excessive
  straining during defecation.
• Rectal prolapse is often associated with other
  conditions such as
• Pinworms(Enterobiasis)
• Cystic fibrosis
• Malnutrition and malabsorption (Celiac
  disease)
• Constipation
• Prior trauma to the anus or pelvic area

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Rectal prolapse

• SymptomsThe main symptom is a protrusion of a
  reddish mass from the anal opening, especially
  following a bowel movement.
• Treatment
• Treating the underlying condition
• In children, Conservative treatment
• The rectal mass may be returned to the
  rectum manually
• Surgical correction for complete rectal
  prolapse
• Complications
• Constipation
• Malnutrition or malabsorption
• Other complications of underlying
  condition

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Proctitis

• An inflammation of the rectum causing discomfort,
  bleeding, and occasionally, a discharge of mucus
  or pus, And the anus may also be involved.
• Causes
• Sexually-transmitted diseases(gonorrhea,
  herpes, Syphilis ,chlamydia, and lymphogranuloma
  venereum.
• Non-sexually transmitted infections(
  Beta-hemolytic streptococcus , Amoebic dysentry,
  Bilharzial dysentry)
• Autoimmune diseases (Ulcerative colitis and
  crohns disease)
• Tuberculous proctitis
• AIDS
• Radiation Proctitis
• noxious agents

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Proctitis

• Symptoms
• pain, discomfort
• rectal bleeding
• rectal discharge, pus
• stools, bloody
• constipation
• Tenesmus
• Tests
• proctoscopy
• sigmoidoscopy
• rectal culture

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Proctitis

• Treatment treatment of the underlying cause
  usually cures the problem. Proctitis caused by
  infection is treated with antibiotics specific
  for the causative organism. Corticosteroid or
  mesalamine suppositories may relieve symptoms in
  Crohn's disease or ulcerative colitis.

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Benign tumours of the rectum(POLYPS)

• A polyp is a lesion that projects into the lumen
  
• Polyps are commonly found
• in vascular organs
• Polyps bleed easily
• The rectum and sigmoid colon
• are common sites of polyps
• Symptoms and signs of polyps
• passage of blood and
• mucus PR
• Rarely obstruction or
• intussusception

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Types of Polyps

• Juvenile Polyps
• Commonest form of polyps in children
• Are red pedunculated spheres lesions
• Can occur throughout large bowel but are most
  common in the rectum
• Usually present before 12 years
• Present with Prolapsing lump or rectal bleeding
• Have little malignant potential
• Treated by local endoscopic resection

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Adenomatous Polyps

• Are pedunculated lesions
• Mainly occur in the rectum and sigmoid colon
• Are often asymptomatic but may produce anaemia
  from chronic occult bleeding
• May give rise to crampy pain
• May secrete mucus
• Have malignant potential
• Treated by colonoscopic polypectomy

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Villous Papillomas

• Are flat, sessile lesions within the rectum
• Secrete copious amount of mucus producing
  spurious diarrhoea
• Present with hypokalemia
• Significant risk of malignant change
• Treated by transanal excision of complete lesion
• If lesion is extensive, mucosal proctectomy and
  coloanal anastomosis should be done

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Familial Polyposis

• Is an autosomal dominant syndrome diagnosed when
  a patient has more than 100 adenomatous polyps
• Due to mutation on long arm of chromosome 5
• May be asymptomatic but bleeding,, abdominal
  pain and diarrhoea are all likely symptoms
• The risk of devoloping carcinoma is virtually
  100
• within 15 years
• The most appropriate treatment is
  panproctocolectomy
• with ileal pouch-anal anastomosis