ANORECTAL

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ANORECTAL DISORDERS
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• Introduction
• Surgical Anatomy
• Congenital Abnormalities
• Examination of the Anus
• Common Anal Conditions

ANORECTAL DISORDERS
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Anal and perianal disorders makeup about 20
of all outpatient Surgical referrals. These
conditions are extremely distressing and
embarrassing patient often put up with symptoms
for long time, before seeking medical care.
I N T R O D U C T I O N
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• The common anal symptoms are
• Anal bleeding
• Anal pain and discomfort
• Perianal itching and irritation
• something coming down
• perianal discharge

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SURGICAL ANATOMY
The anal canal 1.5 (4 cm) long and is directed
downward and backward from the rectum to end at
the anal orifice.
The mid of anal canal represents the junction
between endoderm and ectoderm
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• The lower ½ is lined by squamous epithelium and
  the upper ½ by columnar epithelium so carcinoma
  of the upper ½ is adenocarcinoma. Where as that
  arising from the lower part is squamous tumour.
• The blood supply of upper ½ of the anal canal
  is from the superior rectal vessels. Where as
  that of the lower ½ is supply of the surrounding
  anal skin the inferior rectal vessels which
  derives from the internal pudendal ultimately
  from the internal iliac vessels.

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• The lymphatic above the muco cutaneous junction
  drain along the superior rectal vessels to the
  lumbar lymph nodes, where as below this line
  drainage is to the inguinal lymph nodes.
• The nerve supply to the upper ½ via autonomic
  plexus and the lower ½ is supplied by the somatic
  inferior rectal nerves terminal branch of the
  pudendal nerve. So the lower ½ is sensitive to
  the prick needle.

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• This comprises-
• The internal anal sphincter of in voluntary
  muscle, which is the contination of the circular
  muscles of the rectum.
• The external sphincter of the voluntary muscles,
  which surrounds the internal sphincter and
  comprises 3 parts (formerly)
• ? subcutaneous the lower most portion of the
  external sphincter
• ? superficial part
• ? deep part
• (now considered to be one muscle)

The anal sphincter-
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CONGENITAL ABNORMALITIES

• There are two main types-
• High abnormality more serious because it is
  associated with poor development of the pelvic
  muscles.
• Low abnormality which is simply to treat- These
  abnormalities should be diagnosed at birth is the
  standard physical examination of the new born
  infant. If the diagnosis missed the infant
  developed symptoms and signs of large bowel
  obstruction.

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High abnormalities

• ? The rectum stops short of the pelvic floor and
  the anal canal is absent.

Low abnormalities
? The abnormality is usually either ectopic or
covered anus.
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Diagnosis-

• On physical examination.
• If the baby fail to produce meconium stool in
  the first few hours of life.
• Investigation urine for meconium, if no
  meconium is visible the site of the anus marked
  with metal and x-ray taken for the baby up side
  down so gas shadow may helps to show the distal
  point of bowel development.

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Treatment-

• need early and vigorous treatment in infancy.
• Low abnormalities should be treat by cutback
  type operation followed by regular digital
  dilatation by the mother.
• High abnormalities should be treated by
  colostomy in the 1st few days followed by some
  sort pull through operation at the age of one
  year.

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EXAMINATION OF THE ANUS

• This requires careful attention to circumstances
  (couch, light, gloves). The Sims (left lateral
  position) is satisfactory. The examination
  proceed by
• ? inspection
• ? digital examination with index finger
• ? proctoscopy
• ? sigmoidoscopy

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Common anal conditions

• ? Rectal prolapse
• ? Anal in continence
• ? Haemorrhoids
• ? Pruritus ani
• ? Anorectal abscess
• ? Anal fissure
• ? Anal fistula
• ? Non malignant strictures
• ? Anal neoplasms

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ANAL INCONTINENCE
Normal anal continence depends on an intact
spinal cord reflex acting on an adequate
sphincteric mechanism under cortical inhibitory
control.
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Causes of incontinence-

• ? Congenital malformations of the anus in which
  the sphincter is partially or completely
  lacking.
• ? Trauma. e.g accidental injury, obstetrical
  tears or operative trauma
• ? Anorectal disease e.g. rectal prolapsed,
  piles, chronic inflammatory bowel disease,
  faecal impaction, destruction as carcinoma of
  anus.
• ? Medical conditions e.g., mental deficiency,
  senility and spinal cord lesions.
• ? Neurological and physiological diseases e.g.
  spina bifida, spinal tumours and trauma.

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Clinical Features

• The following are the clinical types
• True incontinence
• Partial incontinence
• Overflow incontinence

A
B
C
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• There is no satisfactory treatment
  for many causes of incontinence.
• Conservative measure satisfactory for minor
  degree of incontinence e.g., anorectal
  lesion, faecal impaction and the sphincter
  tone improved by daily exercises.
• Operative treatment this depend on the
  causes of incontinence.
• ? Thierschs operation
• ? Obstetrical injury (coloperincorrhaphy)
• ? Sphincteroplasty in cases of traumatic
  post operative incontinence.
• ? Sphincter reefing
• ? Colostomy

TREATMENT
A
B
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HAEMORRHOIDS

• Piles may be internal or external according to
  whether they are internal or external to anal
  orifice.
• The internal Haemorrhoids
• ? They are dilation of the superior
  haemorrhoidal veins above the denate line each
  pile consists of mass of dilated vein, artery,
  some connected tissues and mucosal investment.

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• ? The location of piles, right anterior, right
  posterior and left lateral situated respectively
  11, 7, 3 oclock with patient in the lithotomy
  position, these are give daughter piles.
• ? Degree of piles there are four degree of
  piles.

Aetiology of Haemorrhoids
the causes may be primary or secondary.

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Primary Causes

• These are attributed to several predisposing
  causes
• ? Hereditary factors e.g, structural weakness
  of the vein.
• ? Anatomical factors.
• ? Partial congestion.
• ? Chronic constipation.
• ? Sphincteric relaxation.

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Secondary Causes

• These are due to underlying organic cause such
  as
• ? pregnancy
• ? venous obstruction
• ? straining on micturation
• ? venous congestion
• ? carcinoma of the rectum

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Clinical features of Piles

• ? Bleeding at defecation
• ? Prolapse
• ? Discharge with pruritus ani
• ? Pain
• ? Thrombsed piles

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Assessment and Diagnosis

• ? Careful history
• ? Abdominal Examination
• ? Anorectal Examination
• ? Investigation e.g., proctoscopy

Complications of Piles
? Profuse haemorrhage ? Acute thrombosis
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Treatment of Piles

• ? Conservative treatment
• ? Specific treatment
• ? Injection treatment
• (Gabriel syringe is filled with sclerosat 5
  phenol with almond oil)
• ? Barrons rubber banding
• ? Cryosurgery (using cryosurgical probe and
  liquid nitrogen)
• ? Co2 Laser
• ? Lords manual dilation
• ? Haemorrhoidectomy

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• (Perianal Haematoma)
• due to rupture of dilated anal vein as result
  of sever straining.
• ? sudden onset of painful lump at the anus.
• ? o/e swelling tense tender, bluish in colour
  covered with smooth shining skin.
• ? Treatment LA evacuation if the patient come
  within 48h0, if patient come late conservative
  treatment.
• ? if untreated the haematoma undergoes
• ? resolution
• ? ulceration
• ? supporation to forms in abscess
• ? fibrosis which give rise to skin tag.

External Haemorrhoids
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Rectal Prolapse

• Prolapse of the rectum mainly two types
• ? Partial or incomplete prolapse when the mucous
• membrane lining the anal canal protrudes
  through
• the anus only.
• ? Complete prolapse in which the whole thickness
  of
• the bowel protudes through the anus.
• Rectal prolapse occurs most often at extremes
• of life e.g, in children between 1-5 years of
  age and elderly people. More common in
  female than male.

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AETIOLOGY
In children

• the predisposing causes are-
• ? The vertical straight course of the
  rectum.
• ? Reduction of supporting fat in the
  ischiorectal fossa.
• ? Straining at stool.
• ? Chronic cough.

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In adult

• the predisposing causes depend on type of
  the prolapse.
• ? Advance degree of prolapsing piles.
• ? Loss of sphincteric tone.
• ? Straining from urethral obstruction.
• ? Operations for fistula.
• is generally regarded as sliding hernia of
  the recto vesical or recto vaginal pouch due to
  stretching of the levator and from
  pregnancy, obesity.

Partial prolapse
Complete prolapse
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Clinical Features

• ? Prolapse is first noted during defaecation.
• ? Discomfort during defaecation.
• ? Bleeding.
• ? Mucous discharge.
• ? Bowel habit irregular and may lead to
  incontinence.

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Complications of rectal prolapse

• ? Irreducibility
• ? Infection
• ? Ulceration
• ? Severe haemorrhage from
• one of the mucosal vein
• ? Thrombosis and obstruction of the
  venous returns leading to oedema
• ? Irreducibility and gangrene

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TREATMENT
Prolapse in children

• the prolapse tends to disappear
  spontaneously by the age of 5 years. So
  conservative measures are sufficient.
• ? Conservative treatment constipation and
  straining at stool are avoided and the buttocks
  may be strapped together to discourage prolapse
  during defaecation.
• ? Perirectal injection of alcohol/phenol may
  be used to fix the lax mucosa to underlying
  tissue.

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Prolapsed in Adult

? Provided sphincter tone is satisfactory can
be treated by ligature excision of prolapsed
mucosa. ? Injections of 5 phenol
in oil in submucosa. 10-15ml total.
? Electrical stimulation with sphincteric
exercises.
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• Surgery always necessary, none are ideal.
• ? Thierschs operation
• ? Rectopexy (lock haurt)
• ? Rectosigmoidectomy (Mikuliczs op.)
• ? Ivalon sponge rectopexy (Wells op.)
• ? Ripstein operation
• ? Low anterior resection (minor)

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• The infection usually starts in one of the
  crypts of Morgagni and extends along the related
  anal gland to the inter sphincteric plane where
  it forms as abscess. Soon it tracks in various
  directions to produce different types of
  abscesses which are classified as follows

Pathology
? Perianal abscess (60) ? Ischiorectal
abscess (30) ? Sub mucous abscess (5) ?
Pelvirectal abscess NOTE Patient with
recurrent anorectal abscess always consider
associated underlying diseases such as Crohns,
UC, rectal cancer and active TB.
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Clinical Features

• ? Acute pain
• ? High fever
• ? Swelling
• ? Tenderness with induration
• Incision and drainage and covered by antibiotics.

Symptoms-
Signs-
Treatment-
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Problems in the treatment of Anorectal abscess

• ? Fistula in ano
• ? Recurrence
• ? Inflammatory bowel disease

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FISTULA - IN - ANO

• Defined as track lined by granulation tissues,
  which connects deeply in the anal canal or rectum
  and superficially on the skin around the anus.
  It usually result from an anorectal abscess.
  However the aetiology is uncertain. Anal
  fistulas have well recognized association with
  crohns disease, UC, TB, colloid carcinoma of the
  rectum and lympho granuloma venercum.

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Types of Anal Fistulas

• According to whether their natural opening is
  below or above the anorectal ring
• ? Low level e.g., subcutaneous, low anal, sub
  mucous.
• ? High level open into anal canal at or above
  the anorectal ring e.g., high anal, pelvirectal

A
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• Parks classification according to relation of
  anal sphincter-
• ? Inter sphincteric (70) low level anal
  fistula
• ? Trans-sphincteric (25) high level anal
  fistula
• ? Supra sphincteric fistulae (4).
• ? Extra sphincteric (1) rare type include the
  tract passes outside all sphincter muscles to
  open in the rectum.

B
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Good Salls Rule

• ? Fistulas with external opening in
  relation to the anterior ½ of the anus tend to
  be direct type.
• ? Those with external opening in
  relation to the posterior ½ of the anus usually
  tends to open internally in the posterior
  midline. May extend behind the anal canal or
  both sides forming horse shoe fistula.

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Clinical Features

• The chief symptoms is persistent discharge
  which irritates the skin and causes discomfort at
  the anus may be associated with pain.
• external opening may be seen with palpation
  the tracks is often palpable as cord. P/R
  examination.

O/E
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Investigation

• ? Proctoscopy
• ? Radiology
• ? Biopsy
• (Fistulectomy) always sent track for Bx.

TREATMENT
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Anal Fissure

• Defined as longitudinal tear in the mucosa and
  skin of the anal canal. Commonly posterior
  midline more common in female than male. Lateral
  fissures are so rare there presence suggest
  specific lesions such as, Crohns disease, UC, TB
  or malignancy.

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• may be due to
• ? Tearing of the anal lining by over distension
  of the anal canal during passage of large
  scybalous mass (stool).
• ? Tearing of anal valve or fibrous polyps.
• ? Laceration of the anal canal by sharp FB.
• ? Excessive straining during child birth.

Aetiology
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• The acute anal fissure if not treated
  becomes chronic anal fissures. As result
  secondary pathological changes may occurs
• ? Chronicity
• ? A sentinel pile
• ? Hypertrophied anal papilla
• ? Contracture of the anus
• ? Suppuration

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Clinical Features

• Usually affect, young or middle aged adult,
  common in female than male. Rare in old age may
  occur in infancy and may cause acquired mega
  colon.
• ? Pain during and after defecation.
• ? Constipation
• ? Bleeding
• ? Discharge

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Physical Finding

• ? Fissure or ulcer distal to dentate
  line.
• ? Sentinel Tag
• ? Hypertrophied papilla.
• ? Spasms of the internal sphincter

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TREATMENT

• Conservative Treatment
• ? Stool softeners (laxative)
• ? Sitz baths (10 15 mins.)
• ? Ointments Suppository
• Surgical Treatment
• ? Dilation under anaesthesia (Anal Stretch)
• ? Fissurectomy and dorsal sphincterotomy
• ? Lateral internal sphincterotomy

A
B
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BENIGN STRICTURES

• Stricture of the anus and rectum may be
• ? Congenital
• ? Postoperative
• ? Inflammatory

Aetiology
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Clinical Features

• Progressive difficulty in defaecation
• In cases of inflammatory strictures
• ? Bleeding
• ? Discharge
• ? Tenesmus
• ? Late cases subacute int. obst.
• Note (Pipestem Stools)

1
2
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• Rectal examination reveals the location type
  and degree of the stenosis.
• ? Proctoscopy
• ? Biopsy
• ? Dilation
• ? Superficial external proctotomy
• ? Internal proctotomy

Diagnosis
Investigations
Treatment
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ANORECTAL NEOPLASIA
Benign Tumours

• Epithelial Tumours
• a.) Anal warts (virus)
• b.) Juvenile polyp
• c.) Adenomatous polyps
• d.) Villous papilloma
• e.) Familial polyposis
• f.) Pseudo polypi
• g.) Endo Metrioma

1
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2

• Connective Tissue Tumours
• a.) Fibrous polyp
• b.) Lipoma
• d.) Myoma
• e.) Haemangioma
• f.) Benign Lymphoma

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Malignant Tumours of the Anal Canal

• The lesion is usually squamous
• cell carcinoma.

• Rarely adenocarcinoma, malignant melanoma or
  basal cell carcinoma.

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Squamous cell carcinoma

• Arising from the stratified squamous
  epithelium of the lower ½ of the anal canal. It
  is uncommon and forms less than 5 of all
  anorectal malignancies.

• It is disease of elderly squamous cell
  carcinoma more common in males. The aetiology of
  anal carcinoma unknown but chronic irritation or
  infection may be predisposing factors.

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• the patient may present with
• ? localized ulcer or raised growth with
  irregular ulcerated surface.
• ? History of bleeding.
• ? History of pain with discomfort.
• ? Tenesmus with incontinence.
• ? Discharge.

Clinical Features
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• ? On palpation squamous carcinoma feels hard
  and woody due to invasion of perianal tissues.
• ? P/R examination may prove impossible because
  of stenosis or discomfort.
• ? Inguinal LN are examined carefully as they
  receive lymph from the lower anal canal and
  perianal region and may be the site of
  metastasis.

O/E
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• ? The squamous carcinoma divided into two
  types that spreading above the pectinate line and
  that confined below that line.
• ? Those above the pectinate line treated by
  abdomino perineal excision as for rectal
  adenocarcinoma.
• ? Those below the pertinate line.
• local excision.
• if inguinal LN metastasis present should
  be removed by block dissection.
• ? Palliative colostomy late cases.
• ? Radiotherapy.

TREATMENT
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Rare Malignant Anal Tumours

• ? Adenocarcinoma
• ? Basal cell carcinoma
• ? Malignant melanoma

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Sphincters of the anus
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