Download MBBS Surgery Presentations 1 Anal Canal Hemrrhoids Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Surgery 1 Anal Canal Hemrrhoids PPT-Powerpoint Presentations and lecture notes


Anal Canal

Fissure In Ano

Haemorrhoids

Anorectal Anatomy

Arterial

Supply

Nerve Supply

Inferior rectal

Sympathetic: Superior

A middle

hypogastric plexus

rectal A

Parasympathetic:

Venous drainage

S234 (nerviergentis

Inferior rectal V

middle rectal V

Pudendal Nerve:
Motor and sensory

3 hemorrhoidal

complexes
L lateral

Anal canal

R antero-lateral

Anal verge

R posterolateral

Lymphatic drainage
Above dentate: Inf. Mesenteric
Below dentate: internal iliac






?Pain?

-> painless
?Bright red bleeding

?Prolapse associated

with defecation

Internal

External

?Anoderm

?Swell, discomfort,

difficult hygiene

?Pain?

-> Thrombosed

Background

?

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 This combination

?

is only in 19%

R posterior

?

But can be found anywhere in anus

?

Prevalence is 4%

?

Miss labelling by referring

physicians and patients is common
Pathogenesis

Abnormal haemorrhoids are dilated cushions of

arteriovenous plexus with stretched suspensory

fibromuscular stroma with prolapsed rectal mucosa

3 main processes:
1. Increased venous pressure
2. Weakness in supporting fibromuscular stroma
3. Increased internal sphincter tone

Risk factors

Habitual

Pathological

1. Constipation and straining

1. Chronic diarrhea (IBD)

2. Low fibre high fat/spicy

2. Colon malignancy

diet

3. Portal hypertension

3. Prolonged sitting in toilet

4. Spinal cord injury

4. Pregnancy

5. Rectal surgery

5. Aging

6. Episiotomy

6. Obesity

7. Anal intercourse

7. Office work
8. Family tendency




Classification

Origin in relation to Dentate line

Degree of prolapse through anus

1.

Internal: above DL

?1st: bleed but no prolapse

2.

External: below DL

?2nd: spontaneous reduction

3.

Mixed

?3rd: manual reduction

?4th: not reducable

Thrombosed external piles


First-degree internal piles viewed through anoscope

Second-degree internal prolapsed piles, reduced

spontaneously


Third-degree internal prolapsed piles, requiring

manual reduction

Fourth-degree strangulated internal and thrombosed

external piles
Clinical assessment

History ( Ful history required)

Examination

Haemorrhoid directed:

Local

?Pain acute/chronic/ cutaneous

?Inspect for:

?Lump acute/ sub-acute

?Lumps, note colour and reducability

?Prolapse define grade

?Fissures

?Bleeding fresh, post defecation

?Fistulae

?Pruritis and mucus

?Abscess

General GI:

?Digital:

?Change in bowel habit

?Masses

?Mucus discharge

?Character of blood and mucus

?Tenasmus/ back pain

?Perform proctoscopy and

?Weight loss

sigmoidoscopy

?Anorexia

?Other system inquiry

General abdominal examination

Investigations

The diagnosis of haemorrhoids is based on clinical assessment

and proctoscopy

Further investigations should be based on a clinical index of

suspicion

?

Lab: CBC / Clotting profile/ Group and save

?

Proctography: if rectal prolpse is suspected

?

Colonoscopy: if higher colonic or sinister pathology is suspected


Complications

1. Ulceration

2. Thrombosis

3. Sepsis and abscess formation

4. Incontinence

Thrombosed external

haemorrhoids

Thrombosed internal

haemorrhoids


Internal Haemorrhoids Treatment

Conservative Grade 1&2

Measures

? Dietary modification: high fibre diet

? Stool softeners

? Bathing in warm water

? Topical creams NOT MUCH VALUE

Minimally

Indicated in failed medical treatment and grades 3&4

invasive

?

injection sclerotherapy

?

Rubber band ligation

?

Laser photocoagulation

?

Cryotherapy freezing

?

Stapled haemorrhoidectomy

Surgical

Indications:

1.

Failed other treatments

2.

Severely painful grade 3&4

3.

Concurrent other anal conditions

4.

Patient preference




Excision of thrombosed external hemorrhoid.


Closed hemorrhoidectomy

Placement of stapling device obturator

Grade 4 hemorrhoid before reduction

Stapling device


External Haemorrhoids 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

Anal Fissure

Linear tears in the anal mucosa exposing the internal sphincter
90% are posterior
? Young & middle aged adults
? Male = Female
? Location ? posterior midline (most common)

Anterior midline fissures ? more common in females

? In any event, length of each fissure is remarkably constant,

extending from the dentate line to the anal verge and
corresponding roughly to the lower half of the internal
sphincter

Pathology

? Acute fissures ? heal promptly with conservative

treatment

? Secondary changes if present, it does not heal

readily

? Sentinel pile

? Hypertrophied anal papil a

? Long standing

? Fibrous induration in lateral edges of fissure

? Fibrosis at the base of ulcer (internal sphincter)

? At any stage

? Frank suppuration ? intersphincteric / perianal abscess
Etiology

? Initiation ? trauma
? Why midline posterior fissures are more common?
? Dietary factors

? Decreased risk ? raw foods, vegetables, whole grain bread

? Increased risk ? white bread sausages etc.

? Secondary fissure

? Crohn's disease

? Previous anal surgery, especially hemorrhoidectomy

? Fistula-in-ano surgery

? Anterior fissure in females resulting from childbirth

? Long standing loose stools with chronic laxative abuse

? Initiation ? trauma
? Perpetuation of fissure ? abnormality of internal anal

sphincter

? Higher resting pressure within the internal anal sphincter in

pts with fissures than in normal control

? Rectal distension reflex relaxation of internal anal

sphincter overshoot contractions in these patients

sphincter spasm and pain

? Elevated sphincter pressures cause ischemia of the anal

lining resulting in pain and failure to heal

? Posterior commissure perfused more poorly than the other

portion of the anal canal
Clinical Features

? Pain and spasm

? Sharp, agonizing during defecation, recurrent, worsens

constipation.

? Bleeding

? In small amounts,
? approximately 70% of patients note bright red blood on

the toilet paper or stool

? Discharge

? Irritation and pruritis ani due to malodorous discharge of

the pus

? Constipation

Painless non-healing fissure with occasional bleed ? may be a

progenitor of IBD

Diagnosis

? Inspection ? Acute fissure is seen as Linear tear

? most important

? Palpation
? Anoscopy
? Sigmoidoscopy
? Biopsy
Differential diagnosis

? Anorectal suppuration
? Pruritus ani
? Fissure in inflammatory bowel disease
? Carcinoma
? Syphilitic fissures
? Tuberculous ulcer
? Anal abrasion

Treatment

Acute Fissure

Stool-bulking agents

Warm sitz bath

Healed (80%)

Non-healed (20%)

0.2% Nitroglycerin or 2%

Nifedipine or Diltiazem 4-6 wks

Repeat treatment with

alternate medication

Non-healed (30%)

Healed (70%)

Chronic fissure

Botulinum toxin A

Open LIS 98% healing

Closed LIS

injection


Acute anal fissure:
? Spontaneous healing, High fiber diet, adequate water intake

and warm sitz bath, stool softener/bulk laxative, suppositories

? Sodium tetradecyl sulphate

? Chronic anal fissure:

? Conservative

? Surgical
Pharmacological Sphincterotomy

? Pharmacological manipulation of anal sphincter tone as an

alternative modality to surgery for the treatment of anal fissure

? Shares the same goal as lateral sphincterotomy without its

possible long-term side effects

? Pharmacological agents lower anal canal resting pressure

producing chemical sphincterotomy without causing permanent

damage to the anal sphincter mechanism

? By enhancing internal anal sphincter (IAS) relaxation via

? nitric oxide donation

? intracellular Ca2+ depletion

? muscarinic receptor stimulation

? adrenergic inhibition

? This improves blood supply at the site of the fissure that would

promote healing of anal fissures

? Nitric oxide donors and calcium channel blockers, agents that

directly reduce resting anal pressure, has now largely replaced

traditional surgical methods as first-line treatment for chronic anal

fissure
Other Agents

? Botulinum Toxin A

? L-arginine

? Gonyautoxin

? Topical sildenafil

This post was last modified on 08 April 2022