SHAHIRAH ALIYA BINTI ABD KAMAL63

ANAL AND PERIANAL DISEASE

INTRODUCTION• The length of the anal canal is about 4 cm (range, 3-5 cm), • 2/3rd of this being above the dentate line• 1/3rd below the dentate line.

ANATOMY• SURGICAL anal canal : Begins where the rectum passes through pelvic diaphragm and ends at the anal verge• ANATOMICAL anal canal : At the junction of the puborectalis portion of the levator ani muscle and the external anal sphincter, and extends distally to the anal verge.• ANORECTAL RING :-Junction between rectum and anal canal-Upper border of puborectalis and external spinchter complex-Formed by:Deep external sphincter + Conjoined longitudinal muscle + internal spinchter (highest part)

TERMS• Anal verge : Junction between perianal skin and anal canal• Dentate line/pectinate line : Junction btw proctodeum below and post allantoic gut above • Anal columns of Mortgagni• Anal valves• Anal sinuses and crypts• Anal glands

•MUSCLES of anal canal:-External sphincter-Puborectalis muscle-Internal sphincter-Longitudinal Muscle• EXTERNAL SPINCTER-Subdivided into subcutaneous superficial and deep-Attached anteriorly to perineal muscle and posteriorly to coccyx-voluntary muscle (skeletal muscle) and innervated by pudendal nerve

INTERNAL SPHINCTER

• Thickened distal continuation of circular muscle coat of the rectum and ends 0.5cm below dentate line

• Always in tonic state of contraction

• Involuntary (smooth muscle) and 2.5cm long.

• F(x):Maintain the anorectal angle, form the anorectal bundle, and maintain continence.

• Innervated by ANS and intrinsic NANC (non-adrenergic non-cholinergic) fibres → release of NO→ sphincter relaxation

• Parts of Levator Ani muscle• Innervated by sacral somatic nerves• F(x):-Maintain position and length of anal canal-Angle of anorectal junction-Continence mechanism

• Space btw external sphincter and longitudinal muscle• Contains intersphicteric anal glands• Route of spread of pus• Can be opened for sphincter surgery

PUBORECTALIS MUSCLE

INTERSPHICTERIC PLANE

• Continuation of smooth muscle of the outer muscle coat of rectum• Caudally it splits into

multiple septum:-inferiorly:surround S.C portion of external sphicter→skin-medially:across the internal sphincter→submucosal space-laterally:external sphincter + ischiorectal space→fascia of pelvic side wall

F(x) Widens the

lumenFlatten anal cushionShorten anal canalEverts anal margin

LONGITUDINAL MUSCLE

EPITHELIAL AND SUBEPITHELIAL

True anal skinPigmented + hair + sebaceous gland

Anal canal skin/AnodermThin and shiny white squamous epithelium without appendages

Below valves(dentate line)Transit to stratifiedsquamous epithelium

Above the anal valvesRed then Plum cuboidal epithelium

Rectum mucosa and anorectal ringPink columnar epithelium

• ANAL CUSHION:-Uneven mucosal and submucosal folds above dentate line-Painless , it has 3 common position(Left Lateral , Right Anterior , and Right Posterior)-Submucosa lies btw epithelial layer and internal Sphincter-Contain vascular , muscular and connective tissue

BLOOD SUPPLY• Supplied by superior, middle and inferior rectal arteries

VENOUS DRAINAGE•Upper ½ of anal canal : 1. Superior rectal veins tributaries of the inferior

mesenteric vein Portomesenteric venous system2. Middle rectal veins internal iliac veins• Lower ½ of the anal canal: Inferior rectal veins + Subcutaneous perianal plexus of veins eventually join the internal iliac vein on each side

• Upper ½ of anal canal drains ↑ into postrectal lymph nodes inferior mesenteric chain para aortic nodes

• Lower ½ of anal canal drains each side into superficial inguinal group deep inguinal group of lymph node

• Found in submucosa and intersphincteric space• Drain into anal sinuses at the level of dentate line• Their function is unknown; secretes mucin which lubricates the anal canal ease defaecation• Intersphicteric anal gland potential source of anal sepsis

-acute:perianal sepsis,ischiorectal sepsis,pelvic sepsis-chronic:cryptoglandular anal fistula

Lymphatic drainage Anal glandpara

EXAMINATION OF ANUS• Inform the patient• Ask for consent• Call for attendant• Proper exposure and position-Left lateral (Sims position)-prone Jack-Knife position-Lithotomy position

• Per rectal examination: Inspection Digital examination Proctoscopy/sigmoidoscopy

Inspection • Any skin lesions (e.g:psoriasis,lichen planus)• Genital exm:warts,candidiasis• Anal tags,sentinel piles,fistula in ano, pilonidal sinus, and

carcinoma can be diagnosed

Digital examination• Lubricated index finger• Palpate perianal region (e.g:induration,tenderness)• Within the lumen :tone ,length • In the wall• Outside the wall ( anterior, right lateral , left lateral and

posterior) -Bimanual examination -Abdominal examination -Lymph nodes

• On withdrawal: stool colour,mucus,blood or pus

Proctoscopy• Detail inspection can be done• Perform minor procedure (e.g:treatment of

hemorrhoid by injection/band)• Biopsy can be takenSpecific investigation• Sigmoidoscopy• Colonoscopy• X-ray: Straight X-ray of the abdomen , Chest X-ray• Barium enema X-ray • CT scan and Ultrasonography

CONGENITAL ANOMALIESEMBROLOGY• Cloaca becomes two parts: 1) dorsal (rectum) 2) ventral (urogenital)• Cloaca is separated from surface ectoderm of the embryo by the cloacal membrane• Dorsal part (anal membrane) composed of outer layer of ectoderm + inner layer of endoderm• Resorption of this anal membrane by 8th week anal canal• Anal canal is developed from fusion of postallantoic gut with proctodeum.• The junction of these is the dentate line or pectinate line. Anal valves of Ball are remnants of proctodeal membrane .

Imperforated Anus

• Atresia/Agenesis• Divided into two main group – high and

low• Depends on termination of the rectum

in relation to pelvic floor• Low defect:• M=F : rectoperitoneal fistula• M : Rectrobulbar fistula• F : Rectovestibular fistula • easy to correct; prone to constipation

• High defect:• Fistula into bladder neck• difficult to correct ; prone to faecal

incontinence• Persistant cloaca:one opening in

perineum

Management• Investigation :clinical examination Lateral prone radiography (after 24 hours)• Treatment : -First 24 hours : IV fluid correction and antibiotics + evaluate asst. abnormality-Surgery: Anioplasty (low and perineal fistula) Early colostomy + Posterior Sagittal Anorectoplasty

PSARP +/- transabdominal mobilisation of left colon + division of any relation with urinary tract (complex) PSARP + Vaginal and urinary reconstruction (cloaca) Anal dilatation programme

POST–ANAL DERMOID• Soft cystic swelling occupying the space in front of the lower part of the sacrum and coccyx (Hollow)

• Asymptomatic until adult life

•Difficulty to defecate due to its size

•Unlikely to be discovered unless a sinus communicating with the exterior is present / develops as an inflammation

• Cyst easy to palpate per rectum

Dd(x)• anterior sacral

meningiocele (enlarges when the child cries and is associated with paralysis of lower limbs +incontinence

• Pilonoidal sinus

• Anal fistula

Confirm ?• Press over

sacrococcyngeal region in rectum→ sebaceous discharge

• Contrast media+radiography → bottle neck cyst

Treatment • Excision• Remove cocyx-if

large/child with presacral dermoid

POST-ANAL DIMPLE• Fovea coccygea is a dimple in the skin beneath the tip of the coccyx• No consequences found

PILONIDAL SINUS• Location:in the natal cleft overlying the coccyx•One or more non-infected midline openings which communicate with a fibrous track lined by granulation tissue and containing hair lying loosely within the lumen• ‘Jeep disease ‘• Age 20-29 years• Etiology: -Congenital-Acquired; Interdigital pilonidal sinus (hairdresser)

Buttock friction+sheari

ng force

Broken hair drill through

the skin

Track/sinus formation

Secondary track spread

laterally

Discharging opening to skin (lined granulation

tissues)

Dark-hairedAfter puberty till 40 years

Intermittent pain,swelling and discharge at the base of the spine

H/o repeated abscess that have burst spontaneously/have been incised AWAY from midline

PATHOGENESIS CLINICAL FEATURES

Infected hair follicle + buttock

movt.

Sucked into S.C layer

Midline track

MANAGEMENT

• If symptom is minor: Clean the tracks Remove all hair Regular shaving that area Strict hygiene

ACUTE EXACERBATION (ABSCESS) Rest,bath,local antiseptic,

broad spectrum antibiotic Drained through small

longitudinal incision made over abscess and off the midline + curettage of granulation tissue and hair

• Excision:-Laying open +/- marsupilisation-With/without 1⁰ closure-Closure by other means:Z-plasty, Karydakis procedure

• Bascom’s procedure involves:

1.Incision lateral to the midline to gain access to the sinus cavity( get rid of hair and granulation tissue)2.Excision and closure of the midline3. The lateral wound is left open

CONSERVATIVECHRONIC (SURGERY)

ANAL INCONTINENCEETIOLOGYCongenital/childhood • Anorectal anomalies• Spina bifida• Hirschsprung’s disease• Behavioural

Acquired/adulthood• Diabetes Mellitus• CVA• Parkinson’s disease• Multiple sclerosis• Spinal cord injury• GI infection• Irritable Bowel Syndrome• Metabolic bowel syndrome

• IBD• Anal trauma/abdominal

surgery/pelvic• Pelvic malignancy• Rectal prolapse• Rectal evacuation disorder• Anal surgery• Obstetric event

General• Ageing• Dependance on nursing care• Psychobehavioral factors• Intellectual incapability• Drugs:• primary constipating and

laxative

Spinctericcause

neuropathic

structuralAnal surgery

traumaObstetric damage

MANAGEMENTCONSERVATIVE-stool bulking/constipating agent-nurse-led bowel retraining-anal plugs

SURGICAL• Operation to reunite divided

sphincter muscles• Operation to reef the

external sphincter and puborectalis muscle

• Operation to augment the anal sphincter

-if the function cant be restored,we can augment by transposition (gluteus maximus and gracilis) / artificial sphincterSacral nerve stimulationPTNS

HEMORRHOIDDefinition:• It is a dilated plexus of haemorrhoidal veins in the anal

cushion, in relation to anal canal.• CLASSIFICATION :-• Primary/Idiopathic haemorrhoids-familial or genetic,upright position• Secondary haemorrhoids – carcinoma of rectum, ascites,paraplegia, pregnancy.• Depending upon the location of haemorrhoids –internal, external, interno-external

• LOCATION (lithotomy position)

Theories of development• VENOUS OBSTRUCTION-Portal hypertension and varicose veins-Pregnancy,ascites,pelvic tumor• INFECTION-2⁰ to trauma during defecation→ weakening of venous wall• DIET -Fibre-deficient diet (western cuisine)DEFECATION HABIT-Straining-Sitting for prolong periods on lavatory• ANAL TONE-hypertonia • AGEING

CLINICAL FEATURES• Bright red painless bleeding-on wiping/Splash in pan• Mucous discharge• Prolapse• Pain only on prolapseGRADINGGRADES FEATURES SYMPTOMS

1 Never prolapse Bleeding per rectum2 Prolapse on defecation

Spontaneous reductionSomething coming down and going back

3 Prolapse on defecation require manual reduction

Something coming down, bleeding, mucus discharge, pruritis

4 Permanent prolapse Acute pain, throbbing discomfort

COMPLICATIONS OF HAEMORRHOIDS• Chronic anemia• Ulceration• Thrombosis and strangulation• Fibrosis• Portal pyaemia• Gangrene

INVESTIGATIONS• Per rectal examination – thrombosed or fibrosed• Proctoscopy or Sigmoidoscopy

MANAGEMENTCOMPLICATION-Strangulation,thrombosis and gangrene→ analgesic + bed rest +frequent hot bath +compression

-Severe hemorrhage→bleeding diathesis/on anticoagulant→Local compression (adrenaline solution) +morphine inj. +blood transfusion

TREATMENT• Conservative-medical-Invasive therapy

*sclerosing inj.*band ligation*cryotherapy*infrared photocoagulation

• Operative treatment-hemorrhoidectomy

NON OPERATIVE • Fibre supplementation• Increased fluid intake• Bulk purgative• Suppositories • Reading in toilet to be

discouraged (respond to call and do not strain)

• Encourage to lose weight

INVASIVE THERAPY• Injection of sclerosant – Subbmucosal injection of 5

ml of 5 % phenol in almond/arachis oil

Using Gabriel syringe at apex of pedicle

reassessed after 8wks

Barron`s band application -put a elastic band at the base of pedicle-ishemic→slough off + bleeding (after 10 days)

HEMORRHOIDECTOMYDefinition:-Excision of the pile masses up to base.

• Indicated in Grade II and III• It can be done by 3 methods :-OPEN METHOD – Milligan Morgan ligature and excision CLOSED METHOD – Hill-Ferguson STAPLER HAEMORRHOIDOPEXY – Non-excisional procedure• Complications of haemorrhoidectomy• Early = Pain, Acute retention of urine,Reactionary haemorrhage• Late = Secondary haemorrhage, Anal stricture, Anal fissure, Incontinence

CLOSED OPERATION• Same procedure like open but the difference is the defect will be closed by continuous suture

STAPLED HEMORRHOIDEXTOMY

REFERENCE