Anorectal Anatomy
Arterial
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Supply
Nerve Supply
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Inferior rectalSympathetic: Superior
A middle
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hypogastric plexus
rectal A
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Parasympathetic:Venous drainage
S234 (nerviergentis
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Inferior rectal V
middle rectal V
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Pudendal Nerve:Motor and sensory
3 hemorrhoidal
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complexesL lateral
Anal canal
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R antero-lateralAnal verge
R posterolateral
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Lymphatic drainage
Above dentate: Inf. Mesenteric
Below dentate: internal iliac
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?Pain?-> painless
?Bright red bleeding
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?Prolapse associatedwith defecation
Internal
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External
?Anoderm
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?Swell, discomfort,difficult hygiene
?Pain?
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-> Thrombosed
Background
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?They are part of the normal anoderm
cushions
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?
They are areas of vascular
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anastamosis in a supporting stromaof subepithelial smooth muscles.
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The contribute 15-20% of the normal
resting pressure and feed vital
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sensory information .?
3 main cushions are found
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?
L lateral
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?R anterior This combination
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is only in 19%
R posterior
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?But can be found anywhere in anus
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Prevalence is 4%
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Miss labelling by referringphysicians and patients is common
Pathogenesis
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Abnormal haemorrhoids are dilated cushions ofarteriovenous plexus with stretched suspensory
fibromuscular stroma with prolapsed rectal mucosa
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3 main processes:
1. Increased venous pressure
2. Weakness in supporting fibromuscular stroma
3. Increased internal sphincter tone
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Risk factors
Habitual
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Pathological1. Constipation and straining
1. Chronic diarrhea (IBD)
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2. Low fibre high fat/spicy
2. Colon malignancy
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diet3. Portal hypertension
3. Prolonged sitting in toilet
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4. Spinal cord injury
4. Pregnancy
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5. Rectal surgery5. Aging
6. Episiotomy
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6. Obesity
7. Anal intercourse
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7. Office work8. Family tendency
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Classification
Origin in relation to Dentate line
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Degree of prolapse through anus1.
Internal: above DL
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?1st: bleed but no prolapse
2.
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External: below DL?2nd: spontaneous reduction
3.
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Mixed
?3rd: manual reduction
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?4th: not reducableThrombosed external piles
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First-degree internal piles viewed through anoscopeSecond-degree internal prolapsed piles, reduced
spontaneously
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Third-degree internal prolapsed piles, requiring
manual reduction
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Fourth-degree strangulated internal and thrombosed
external piles
Clinical assessment
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History ( Ful history required)
Examination
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Haemorrhoid directed:Local
?Pain acute/chronic/ cutaneous
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?Inspect for:
?Lump acute/ sub-acute
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?Lumps, note colour and reducability?Prolapse define grade
?Fissures
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?Bleeding fresh, post defecation
?Fistulae
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?Pruritis and mucus?Abscess
General GI:
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?Digital:
?Change in bowel habit
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?Masses?Mucus discharge
?Character of blood and mucus
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?Tenasmus/ back pain
?Perform proctoscopy and
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?Weight losssigmoidoscopy
?Anorexia
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?Other system inquiry
General abdominal examination
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InvestigationsThe diagnosis of haemorrhoids is based on clinical assessment
and proctoscopy
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Further investigations should be based on a clinical index of
suspicion
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?Lab: CBC / Clotting profile/ Group and save
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Proctography: if rectal prolpse is suspected
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Colonoscopy: if higher colonic or sinister pathology is suspectedComplications
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1. Ulceration2. Thrombosis
3. Sepsis and abscess formation
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4. Incontinence
Thrombosed external
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haemorrhoidsThrombosed internal
haemorrhoids
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Internal Haemorrhoids Treatment
Conservative Grade 1&2
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Measures
? Dietary modification: high fibre diet
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? Stool softeners? Bathing in warm water
? Topical creams NOT MUCH VALUE
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Minimally
Indicated in failed medical treatment and grades 3&4
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invasive?
injection sclerotherapy
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?
Rubber band ligation
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?Laser photocoagulation
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Cryotherapy freezing
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Stapled haemorrhoidectomySurgical
Indications:
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1.
Failed other treatments
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2.Severely painful grade 3&4
3.
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Concurrent other anal conditions
4.
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Excision of thrombosed external hemorrhoid.Closed hemorrhoidectomy
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Placement of stapling device obturatorGrade 4 hemorrhoid before reduction
Stapling device
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External Haemorrhoids Treatment
?
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If presentation less than 72 hours:
Enucleate under LA or GA
Leave wound open to close by secondary intension
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Apply pressure dressing for 24 hours post op?
If more than 72 hours:
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? Conservative measures
Anal Fissure
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Linear tears in the anal mucosa exposing the internal sphincter90% are posterior
? Young & middle aged adults
? Male = Female
? Location ? posterior midline (most common)
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Anterior midline fissures ? more common in females
? In any event, length of each fissure is remarkably constant,
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extending from the dentate line to the anal verge andcorresponding roughly to the lower half of the internal
sphincter
Pathology
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? Acute fissures ? heal promptly with conservative
treatment
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? Secondary changes if present, it does not healreadily
? Sentinel pile
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? Hypertrophied anal papil a
? Long standing
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? Fibrous induration in lateral edges of fissure? Fibrosis at the base of ulcer (internal sphincter)
? At any stage
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? Frank suppuration ? intersphincteric / perianal abscess
Etiology
? Initiation ? trauma
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? Why midline posterior fissures are more common?? Dietary factors
? Decreased risk ? raw foods, vegetables, whole grain bread
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? Increased risk ? white bread sausages etc.? Secondary fissure
? Crohn's disease
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? Previous anal surgery, especially hemorrhoidectomy
? Fistula-in-ano surgery
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? Anterior fissure in females resulting from childbirth? Long standing loose stools with chronic laxative abuse
? Initiation ? trauma
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? Perpetuation of fissure ? abnormality of internal analsphincter
? Higher resting pressure within the internal anal sphincter in
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pts with fissures than in normal control
? Rectal distension reflex relaxation of internal anal
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sphincter overshoot contractions in these patientssphincter spasm and pain
? Elevated sphincter pressures cause ischemia of the anal
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lining resulting in pain and failure to heal
? Posterior commissure perfused more poorly than the other
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portion of the anal canalClinical Features
? Pain and spasm
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? Sharp, agonizing during defecation, recurrent, worsensconstipation.
? Bleeding
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? In small amounts,
? approximately 70% of patients note bright red blood on
the toilet paper or stool
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? Discharge
? Irritation and pruritis ani due to malodorous discharge of
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the pus? Constipation
Painless non-healing fissure with occasional bleed ? may be a
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progenitor of IBD
Diagnosis
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? Inspection ? Acute fissure is seen as Linear tear? most important
? Palpation
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? Anoscopy? Sigmoidoscopy
? Biopsy
Differential diagnosis
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? Anorectal suppuration? Pruritus ani
? Fissure in inflammatory bowel disease
? Carcinoma
? Syphilitic fissures
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? Tuberculous ulcer? Anal abrasion
Treatment
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Acute FissureStool-bulking agents
Warm sitz bath
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Healed (80%)
Non-healed (20%)
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0.2% Nitroglycerin or 2%Nifedipine or Diltiazem 4-6 wks
Repeat treatment with
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alternate medication
Non-healed (30%)
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Healed (70%)Chronic fissure
Botulinum toxin A
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Open LIS 98% healing
Closed LIS
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injectionAcute anal fissure:
? Spontaneous healing, High fiber diet, adequate water intake
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and warm sitz bath, stool softener/bulk laxative, suppositories
? Sodium tetradecyl sulphate
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? Chronic anal fissure:? Conservative
? Surgical
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Pharmacological Sphincterotomy? Pharmacological manipulation of anal sphincter tone as an
alternative modality to surgery for the treatment of anal fissure
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? Shares the same goal as lateral sphincterotomy without its
possible long-term side effects
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? Pharmacological agents lower anal canal resting pressureproducing chemical sphincterotomy without causing permanent
damage to the anal sphincter mechanism
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? By enhancing internal anal sphincter (IAS) relaxation via
? nitric oxide donation
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? intracellular Ca2+ depletion? muscarinic receptor stimulation
? adrenergic inhibition
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? This improves blood supply at the site of the fissure that would
promote healing of anal fissures
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? Nitric oxide donors and calcium channel blockers, agents thatdirectly reduce resting anal pressure, has now largely replaced
traditional surgical methods as first-line treatment for chronic anal
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fissure
Other Agents
? Botulinum Toxin A
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? L-arginine
? Gonyautoxin
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? Topical sildenafil