Acute perianal conditions

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Anatomy

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Anatomy of the anal canal• The anal canal is divided

into two unequal sections, upper and lower:

1) The upper 2/3 : Its mucosa is lined by simple columnar epithelium.

2) The lower 1/3 of the anal canal is lined by stratified squamous epithelium .

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Blood Supply

• The upper 2/3 of the anal canal:- is supplied by the superior rectal artery which

is a branch of the inferior mesenteric artery.- Is drained by superior rectal vein inferior

mesenteric vein

• The lower third of the anal canal:- is supplied by the inferior rectal artery which

is a branch of the internal pudendal artery.- Inferior rectal vein internal pudendal vein 4

Physiology

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• The function of the anal canal is to maintain continence.• This function is made by the presence of:

1)Internal sphincter: smooth muscle; involuntary.2)External sphincter: skeletal muscle; voluntary.3)Levator ani muscle: voluntary.4)Dilated cushions: Hemorrhoids; finest closure.

• Resting tone of anal canal is made by: internal sphincter + some external sphincter and levator ani.

Physiology

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Hemorrhoids

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• Pathophysiology:Engorgement and dilatation of the blood vessels leading to stretching of the overlying mucosa and formation of lumps that may prolapse.

Hemorrhoids

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• Classification:1) Internal Vs External hemorrhoids.2) Primary Vs Secondary hemorrhoids.

Hemorrhoids

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• Internal Vs External hemorrhoids:- Internal hemorrhiods: above dentate line (internal plexus)- External hemorrhiods: below dentate line (External plexus)- Mixed hemorrhiods: above and below dentate line.

Hemorrhoids

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• Internal Vs External hemorrhoids: -Internal hemorrhoids = columnar epithelium (pink)-External hemorrhoids = Squamous (opaque)

Hemorrhoids

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• Primary Vs Secondary hemorrhoids:-Primary hemorrhoids: one or more of the main vessels of anal canal are involved (3,7,11 o’clock in lithotomy position)

Hemorrhoids

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• Secondary hemorrhoids: smaller branches are involved• Circumferential hemorrhoids: all around the anal canal

severe condition.

Hemorrhoids

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• Degrees of hemorrhoids: 1st degree: no prolapse outside (only bleeding) 2nd degree: prolapse, spontaneous reduction after defecation 3rd degree: prolapse, manual reduction 4th degree: permanent prolapse (irreducible)

Hemorrhoids

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• Clinical Presentation: Uncomplicated hemorrhoids: heaviness type of pain after

long standing or after defecation. complicated hemorrhoids : Acute sharp pain

Hemorrhoids

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• Complications:Thrombosed hemorrhoids.

- Clinical presentaions : Severe sharp pain in the first 48 hours.- Physical examination: Tender tense blue subcutaneous swelling at anal margin covered by smooth shinny skin.- Management: Most cases resolve spontaneously within 2 weeks with conservative therapy.Some cases may require excision for pain relief. Strangulation (strangulated hemorrhoids may

become gangrenous and slough off) Ulceration

Hemorrhoids

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•ManagementIt depends on the severity of the case and the response of the patient. Conservative:

High fiber diet + Bulk laxatives Interventional (non-surgical):

1. Sclerosing agent injection.2. Cryosurgery.3. Rubber band ligation. Surgical hemorroidectomy

Hemorrhoids

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Anorectal abscess

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• It is a collection of pus in the anal/rectal region.

• - Common in pts between 20-50 years old, but occurs at all ages, rarely, in children.

• - More often in men.

Anorectal abscess

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Pathophysiology• The most acceptable theory is the crypto-glandular

theory:1. Inflammation in the crypts (cryptitis).2. Infection spreads through the ducts to the anal gland

(glandulitis).3. Formation of (intersphincteric abscess) This is the

starting point of anorectal sepsis.

Anorectal abscess

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• Clinical presentation: Throbbing pain; which is aggravated by sitting or movement. Systemic symptoms: Fever, malaise, toxicity...

Anorectal abscess

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>> If the abscess remains there, then the patient will present withintersphincteric abscess.>> If the pus goes down, the collection will be at the anal verge and thepatient will present with a bulge in the perianal skin (perianalabscess).>> If the pus goes up above the levator-ani muscle (supra levatorabscess)>> If the pus can pass through the external sphincter to the ischiorectalSpace (ischiorectal abscess)

So the problem starts in the intersphincteric space but it can end anywhere.

Anorectal abscess

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• Physical examination: depends on the site1. In perianal abscess the perianal skin is red, tender and

swollen.2. In supralevator abscess deep pain with little or no outside

physical findings.3. In intersphincteric abscess, if you do PR examination you'll

find a tender mass.4. In ischiorectal abscess it depends on the site:- in high level little or no external findings- in low level red tender and swollen skin

Anorectal abscess

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Anorectal abscess

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•Management: Incision and drainage

Once you decide to drain the abscess, you have to warn your patient that there is a chance around 50% of recurrence and 50% of fistula formation.

Anorectal abscess

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Pilonidal abscess

and sinus26

The term pilonidal sinus describes a condition found in the natal cleft overlying the coccyx, consisting of one or more, usually non-infected,midline openings, which communicate with a fibrous track lined by granulation tissue and containing hair lying loosely within the lumen.

Pilonidal abscess/sinus

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Pilonidal abscess/sinus• It is thought that the combination of buttock friction and shearing forces in

that area allows shed hair or broken hairs which have collected there to drill through the midline skin

•OR that infection in relation to a hair follicle allows hair to enter the skin by the suction created by movement of the buttocks, so creating a subcutaneous, chronically infected, midline track.

• It may occur in: the umbilicus, the axilla, the interdigital area in hairdressers.

• Risk factors:- Males - Hairy - long sitting time

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• Clinical presentation:- Intermittent pain especially if inflamed or with superimposed

infection.- Swelling and discharge

Pilonidal abscess/sinus

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•Management: Conservative

Clean the tract, remove hairRegular ShavingStrict hygiene

Surgical Excision

Acute pilonidal abscess: Usually requires incision and drainage under local anesthesia

Chronic pilonidal sinus: Excision under general anaesthesia with exploration, open and removal of tracts

Pilonidal abscess/sinus

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Anal Fissure

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• It is a tear in the lower part of the anal canal mucosa.• Cause:

Pain

Internal sphincter

spasm

Constipation

Anal Fissure

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Anal Fissure

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• Clinical presentation: Severe Pain: associated with defecation, usually resolves

spontaneously after a variable time to recur again after the next evacuation.

Bleeding with defecation. Constipation. Mucus discharge pruritis.

Anal Fissure

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•Classification: Primary Vs Secondary Acute Vs Chronic

Anal Fissure

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• Primary Vs Secondary: Primary fissures:

- Unknown cause (cycle) - Location: Midline posteriorly 90%Midline anteriorly 10%

Secondary fissures: - ( IBD , HIV , Syphilis , TB , Herpes, Leukemia)- Not at the midline

Anal Fissure

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• Acute Vs Chronic: Signs of chronicity:

- Deep with a lot of fibrosis.- Proximal end of the fissure: Reactionary polyp (hypertrophied anal papilla)- Distal end of the fissure: Sentinel piles or skin tags

Anal Fissure

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•Management: The aim is to break the cycle

A) Conservative:- Treat constipation; high fiber diet and bulk laxatives- Relieve pain: Local analgesics, sitz baths- Relieve spasm: Nitroglycerin, Botulinum toxin, CCB (relax the spasm, improve blood supply to improve healing).

B) Surgery: - Partial lateral internal sphinctertomy: reduces tightness of the internal sphincter by cutting part of it.

Pain

Internal sphincter spasm

Constipation

Anal Fissure

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Herpes infection(vesicles)

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• Sexually transmitted disease.(STD)• Very painful.• In early stage we can treat it

with antiviral drugs, but in late stage we have to wait for the diseaseto limit by itself.

Herpes infection

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Rectal prolapse

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• It is the protrusion of wall of rectum through the anus.

Rectal prolapse

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• Clinical presentation:- Mainly protrusion of a reddish mass from the anal opening,

especially following a bowel movement.- Pain, bleeding, incontinence.• Management:- Conservative : high fiber diet , bulk laxatives - Surgery : abdominal rectopexy

Rectal prolapse

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Proctalgia fugax

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• Attacks of severe pain, arise in the rectum, recur at irregular intervals, unrelated to organic diseases [functional GI disorder]

• Etiology:– No clear etiology – Probably caused by a spontaneous spasm of the pelvic

muscles• Clinical Presentation: Rectal pain

– Comes suddenly at night– Severe, cramp like– Short duration [few minutes]– Disappears spontaneously– May follow stool straining, sudden explosive bowel action

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• Management:-The most common approach is simply reassurance and topical treatment.-Warm baths, hot enemas (if the pain lasts long enough to draw a bath).

- Relaxation techniques, medications.

-In patients who suffer frequent, severe, prolonged attacks, inhaled salbutamol has been shown in some studies to reduce their duration.

-Botulinum toxin has been proposed as analgesic.- Low dose diazepam at bedtime has been suggested as preventative.

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The End 47