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