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  • BenignperianalconditionsDrTonyMakTeam3Refreshercourse2162013

    BenignPerianalConditions Haemorrhoids Fistulainano AnalFissure Rectalprolapse PerianalSexuallytransmitteddiseases Pilonidalsinus

  • Basicassessments

  • Bleeding Pain PruritusAni Swelling Tenesmus Discharge

    Bleeding Haemorrhoidalbleeding:

    brightred

    separate

    paperandbowl

    maydrip

    Beware:darkerbleeding

    bleedingmixedwithstools

  • Analpain Character?Sharp/Dull When?Painondefecation Duration?Lastsfewdays prolonged Associatedsymptoms..SwingingFever.Localswelling

    Proctalgiafugax Severespasmofanalpain Lastonlyafewminutes Oftenatnight

    PruritusAniSystemicillness

    Diabetesmellitus

    Hyperbilirubinemia

    Leukemia

    Aplasticanemia

    Thyroiddisease

    MechanicalfactorsChronicdiarrhea

    Chronicconstipation

    Analincontinence

    Soaps,deodorants,perfumes

    Overvigorouscleansing

    Hemorrhoidsproducingleakage

    Prolapsedhemorrhoids

    Alcoholbasedanalwipes

    Rectalprolapse

    Analpapilloma

    Analfissure

    Analfistula

    Tightfittingclothes

    Allergytodyesintoiletpaper

    Intolerancetofabricsoftener

    Foodsensitivity

    Tomatoes

    Caffeinatedbeverages

    Beer

    Citrusproducts

    Milkproducts

    DermatologicalconditionsPsoriasis

    Seborrheicdermatitis

    Intertrigo

    Neurodermatitis

    Bowen'sdisease

    Varioussquamousdisorders

    Atopicdermatitis

    Lichenplanus

    Lichensclerosis

    Contactdermatitis

    InfectionsErythrasma (Corynebacterium)

    Intertrigo (Candida)

    Herpessimplexvirus

    Humanpapillomavirus

    Pinworms(Enterobius)

    Scabies

    Medications

    Colchicine

    Quinidine

  • Perianalswelling Whereisit?? Doesitcomesandgoes? Isitgettingbigger? Hardorsoft?

  • Examination Inspection

    Scars Externalopening/Sinus Lesions:fissures,thrombosedhaemorrhoids,condyloma Skinconditions:dermatitis

    Palpation Painful? Induration Lesions:Fibroepithelialpolyps,lowrectaltumours Analtone

    Rigidendoscopies(RectumandAnalcanal) Visualconfirmation

  • Haemorrhoids

    Famouspeoplewithtroublesomehaemorrhoids.

  • WereNapoleonshaemorrhoids thecauseofhisdefeatattheBattleofWaterloo?

    KarlMarx(18181883)

  • ErnestHemingway(18991961)

  • ?

  • Mostpatientsassumeproblemswiththeirbottomsareduetopiles

    Haemorrhoids are common,at least 50% of people will suffer

    symptoms at some time

    Analvascularcushionscontributetoanalclosure

  • Haemorrhoids:bloodsupply 6(48)terminalbranchesofSuperiorrectalartery

    Terminal branches from Superior Rectal Artery

    3

    711

    Left lateralLeft lateral

    Right posteriorRight posteriorRight anteriorRight anterior

    Anal Cushions: constant positionAnal Cushions: constant position

  • Gradual loss of support of anal cushions

    Detach from internal sphincter

    Loose and bulge into anal canalDilatation & engorgement of AV plexuses

    Aetiology ofhaemorrhoids

    Aetiology ofhaemorrhoidsThomsonThomson VascularCushionTheoryVascularCushionTheory

    Anatomicalsupportweakens

    Aging(deteriorationafterthethirddecades)

    Straining,increasedabdo pressure

    Hormonalinfluence

    Geneticpredisposition

  • Classification anatomicaloriginInternalInternalhaemorrhoidshaemorrhoids (endoderm)(endoderm) Ariseabovethedentateline Microscopicallycoveredbytransitionalorcolumnarepithelium

    Lackofsomaticsensation

    ExternalExternalhaemorrhoidshaemorrhoids (ectoderm)(ectoderm) Situatedbelowdentateline Microscopicallycoveredbymodifiedskinepithelium

    Goligher Grading

    No protrusion of No protrusion of haemorrhoidshaemorrhoids

    Stage IProtruding haemorrhoids Protruding haemorrhoids that spontaneously that spontaneously reducereduce

    Haemorrhoids

    Stage IIIProtruding Protruding haemorrhoids, haemorrhoids, possible possible to push back in to push back in manuallymanually

    Protruding Protruding haemorrhoidshaemorrhoidsthat canthat cant be pushed back t be pushed back in manually anymore in manually anymore

    Stage IVStage II

  • Bleeding Haemorrhoidal bleeding:

    brightred

    separate

    paperandbowl

    maydrip

    Beware:darkerbleeding

    bleedingmixedwithstools

    Haemorrhoidal symptoms Bleeding Prolapse Burningorpressuresensation Pain(whenthrombosed) Pruritis ani Anaemic symptoms

    Alsoassociatedwithmanyotheranalpathologies

  • Differentialdiagnosis Anal/rectalcancer Perianal haematoma Fissureinano Analskintags Analwarts Prolapse Perianal Crohns disease

    WhodoIinvestigate?

  • Conservativetherapy

    Diet

    Wtloss

    AvoidStraining

    Stoolsofteners

    Topicalcreams

  • Principlesofinvasiveprocedures1.Fixation Injectionsclerotherapy Rubberbandligation Thermalmethods PPH

    2.Excision Haemorrhoidectomy

    3.Destructionofhaemorrhoidal arteries DG HAL/THD Laserphotocoagulation

  • ProcedurescarriedoutinClinicProcedurescarriedoutinClinic

    5% Phenol in almond oil

    INJECTIONSCLEROTHERAPY

    First and Second Degree where bleeding is principle symptom.

    Irritant sclerosant solution (phenol in oil) injected into submucosaproximal to each haemorrhoidal plexus

    Simple, safe , painless

    Complications related to incorrect application.

    Long-term success rate - sparsely reported.

  • RUBBERBANDLIGATION

    Localobliterationofsubmucosal vessels Ischaemic necrosis Ulceration(710dayspostbanding) Fixationofmucosabyfibrosis(theareahealedby34weeks)

    79%symptomaticcontrolbutapproximately33%relapseat5years

    Complications:pain,bleeding,postbandingsepsis

    Apply the band at least1cm above dentate line

    Maximum: up to 3 banding

    Can be repeated

    ThermalMethods Thermalmethodshasbeenusedforhundredsofyearsrangingfromheatingtofreezing

    InfraredLaser

    Diathermy

    Cryotherapy

  • InfraredThermocoagulation Infraredradiationpenetratesthetissuetoapredetermineddepth

    Instantlyconvertedintoheat(slightlyabove1000C)proteindenaturation

    Coagulatevessels&fixthemucosatounderlyingtissues

    Results Safeandwelltoleratedclinicprocedure Worksbestwithsmall1st/2nddegreepiles Almostimmediatereturntonormalactivity LessposttreatmentdiscomfortthanRBL

    Poenetal2000Eur JGastroenterolhepatol

    Inferiortorubberbandligation Higherrateofrecurrence(54%vs27%)

    Walkeretal1990IntJColorectalDis

    Needmultipletreatments

  • Proceduresinclinic Caution Bacteraemia

    Bewareofexistingcardiacdisease

    Presenceofmetallicheartvalve

    Newlyimplantedvasculargraft/artificialjoint

    AnticoagulantTherapy Clopidogrel

    Consider inConsider in--patient treatmentpatient treatment

    ManagementofHaemorrhoidalDisease

    Formanyyearstherehasbeenanincreasingtendencytoperformlessandlesssurgeryforhaemorrhoids.Thisfollowsonfromtheexpectationonbehalfofpatientsandsurgeonthathaemorrhoidectomyisextremelypainfulandrequiresprolongedhospitalstayandtimeoffwork.However,allsurgeonsarefamiliarwiththefrequencyatwhichpatientsreattendovermanyyearswhentreatedbyinjectionsclerotherapyandrubberbandligation.

    PeterLoder,ColorectalSurgery,ACompaniontoSpecialistSurgicalPractice Chapter13(EditedbyRobinKPhillips)

  • OPERATIVEHAEMORRHOIDECTOMY

    ClassificationofHaemorrhoidsDegreeofprolapse

    1st degree - No prolapse 2nd degree - Spontaneously reducible

    3rd degree - Prolapse requiring manual reduction Fourth degree - Permanent prolapse

  • HAEMORRHOIDECTOMY Surgicalexcisionisoneoftheoldesttreatmentsforpiles Mosteffectiveandlongtermcure

  • Dissection continues to top of anal cushionPedicle is ligated and transected(ligature may be unnecessary with

    diathermy)

    Defects left open leaving three raw areasseparated by bridge of skin and mucosa 3-leaf CloverHealing in 5 -6 weeks

    OPENHAEMORRHOIDECTOMY

    CLOSEDHAEMORRHOIDECTOMYFerguson (1959)Haemorrhoidectomy with primary repairPreferred technique in USAProne, jack-knife position

    Defect closed with continuous suture

    Improves healing?Less painful?Reduces stenosis?Post-op morbidity similar Risk of wound dehiscence

  • Technicalmodifications Energysourcefordissection

    Minimizebleeding Avoidpedicletransfixion

    Minimizepostoppain

    ComplicationsOperator dependant

    Often done as day cases but still painful

    Urinary Retention 10-32%

    Formation of skin tags 6%

    Bleeding 2-4%

    Anal Fissure 1-2.6%

    Anal stenosis 1%

    Incontinence

  • Urinaryretention Themostcommoncomplication Predisposingfactors:PainandanalspasmFluidoverloadRectalpackingDrugs(narcotics,anticholinergics)Preexistingoutflowtractobstruction

    Leavethecatheterfor24hrs(RU>500ml)

    Haemorrhage ReactionalhaemorrhageTechnicalerror

    Requiresimmediatesurgicalintervention

    Delayedhaemorrhage(D710postop)Rangingfrommildmassivebleeding

    Warrantsexamination

    Occursin2%haemorrhoidectomies

    Sepsisinthepedicle

    Usuallynotapreventablecomplication

  • Motivesbehindnewdevelopment Pain Hospitalstay Resumenormalactivity Wounddiscomfort Discharge bleeding Continencedisturbance

    Treatmentofhaemorrhoidaldiseasebyreductionofthemucosaandhaemorrhoidalprolapsewithacircularsuturingdevice:ANewProcedure

    AntonioLongoUniversitadiPalermoProceedingsofthe6th WorldCongressofEndoscopicSurgeryand6th InternationalCongressofEuropeanAssociationforEndoscopicSurgery(EAES)77784Rome,Italy.36June1998

  • Procedurefor Prolapseand HaemorrhoidsTheLongoTechnique

    PPH-03 Kit

    Haemorrhoidal Circular Stapler