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Common Office Anorectal Problems

Common Office Anorectal Problems. Sandra J. Beck, M.D., FACS, FASCRS Associate Professor of Colon and Rectal Surgery University of Kentucky Medical Center. Disclosures. None. Benign Anal Rectal Disease. Anatomy of the anal canal and perianal spaces Benign Anal Rectal Disease

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Common Office Anorectal Problems

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  1. Common Office Anorectal Problems Sandra J. Beck, M.D., FACS, FASCRS Associate Professor of Colon and Rectal Surgery University of Kentucky Medical Center

  2. Disclosures • None

  3. Benign Anal Rectal Disease • Anatomy of the anal canal and perianal spaces • Benign Anal Rectal Disease • Abscess and Fistula • Fissure • Hemorrhoids

  4. Overview of Anatomy • Anatomy • Pelvic and Perirectal Spaces • Anatomy of Anal Canal

  5. Retrorectal Space Waldeyer’s Fascia Supralevator Space Levator Ani Muscle Deep Postanal Space Superficial Postanal Space

  6. ANAL CANAL Peritoneum Supralevator Space Levator Ani m. Puborectalis m. Ischioanal Space Deep External Sphincter m. Intersphincteric Space Internal Sphincter m. Perianal Space Transverse Septum

  7. ANAL CANAL Column of Morgagni Anal Transitional Zone Dentate Line Anal Crypt Anal Gland Anoderm

  8. Diagnosis and Treatment of Anorectal Abscess and Fistula-in-Ano

  9. Anorectal Abscess Etiology • Cryptoglandular abscess • Most common • Infection in the glands at the dentate line • Other causes • Crohn’s and Ulcerative Colitis • Tuberculosis and Actinomycoses • Malignancy • Foreign Bodies, Prostate Surgery or Radiation

  10. Fistula Description • Clock description • Does the anus tell time? • Relies on description of patient’s position: supine, lateral, prone and relative landmarks • Anatomic description: more consistent • Pubic bone defines anterior • Coccyx define posterior • Right and left • *If terms be incorrect, then statements do not accord with facts; and when statements and facts do not accord, then business is not properly executed." Confucius 1

  11. Pubic bone Right anterior Left anterior Left Right Right posterior Left posterior Tailbone

  12. There is an area of induration and erythema in the right posterior quadrant that is likely an abscess that has spontaneously drained

  13. Abscess Classification • Four Types Based on Space Involved • Perianal - 19-54% • Intersphincteric - 20-40% • Ischioanal - 40-60% • Supralevator 2% or less Most Common Rare

  14. Supralevator Abscess Intersphincteric Abscess Ischioanal Abscess Perianal Abscess

  15. HORSESHOE ABSCESS Supralevator Space Intersphincteric Space Ischioanal Space

  16. Anorectal AbscessTreatment of Perianal and Ischiorectal Abscesses • Diagnosis - usually straightforward • Erythema and Pain over affected area • Fluctuance • Treatment • Incision and Drainage • +/- Excision of small amount of overlying skin • Initial packing for hemostasis • Drainage catheter (Pezzer) or pack wound • Attention to good hygiene and control blood sugar • Antibiotics if immunocompromised, obese or diabetic

  17. Small Radial incisionShort distance from anus – feel for soft spotPlace drain and trim – avoids packingFollow up in 7-10 days to remove drain

  18. Pezzer catheter Solid mushroom top so stays in Less tissue ingrowth Malecot Allows tissue ingrowth More painful to remove Catheter Types

  19. Peri anal abscess - ? Antibiotics • Not usually indicated if there is adequate drainage • Indicated for patients with: • Obesity • Diabetes • Imunocompromised • Extensive large abscess or recurrent abscess

  20. Fistula-in-Ano • Definition • abnormal connection between two epithelial surfaces. • Classification: • Parks: Defines fistula by course of tract • Goodsall’s rule • Diagnosis • Treatment • Goals • Options

  21. How does patient present? • May have had a history of abscess • History of Crohn’s disease • May present at the same time as abscess • Complain of intermittent increase in pain/swelling followed by spontaneous drainage • Chronic localized area of irritation or ulcer “pimple near my anus keeps coming back”

  22. Fistula-in-AnoGoodsall’s Rule Posterior Anterior

  23. Fistula in ano

  24. Fistula in ano: Surgical disease • Refer to Colon and Rectal Surgeon or General Surgeon • Reassure patient – rarely cancer, most do not need a colostomy • If suspect Crohns • Gain control of perianal sepsis • Then complete full workup and staging • Goals of therapy • Get rid of the fistula/connection • Preserve continence

  25. Surgical Options • Primary fistulotomy • Mainly for low, superficial fistula • Risk of fecal incontinence • Fibrin Glue/Fistula Plug • Utilizes substrate as scaffold to fill tract • Does not involve cutting muscle • Cutting or draining setons • For deeper tracts that involve significant muscle • Risk of fecal incontinence • Rectal advancement flap • Lateral internal fistula transection • Newer procedure. No foreign substrate • Cuts fistula tract, not muscle

  26. Fistula in ano

  27. Fistula in ano

  28. Fissure in Ano • Definition – a painful linear ulcer situated in the anal canal and extending from just below the dentate line to the margin of the anus • Overlie the lower half of the internal sphincter • ~73.5% are posterior • ~16.4% are anterior • ~2.6% both anterior and posterior

  29. Fissure in AnoPathogenesis • Acute fissure results from trauma to the anal canal most commonly from a large fecal bolus • Secondary changes of chronic fissure include • Sentinel pile or skin tag at the distal end • Hypertrophied anal papilla-swelling, edema and fibrosis near the dentate line • Fibrosis of the internal sphincter at the base

  30. Fissure with Sentinel Tag

  31. Fissure with Sentinel Tag

  32. Fissure in AnoPathogenesis • Perpetuating factors in chronic fissure • Persistent hard bowel movement • Abnormal high resting pressure in the internal anal sphincter • Increased pressure in the sphincter causes a decrease in blood flow, preventing healing of the fissure

  33. Fissure in AnoSymptoms • Pain is the main symptom • Sharp, cutting or tearing during defecation • Duration is few minutes to hours • Bleeding – bright red and scant • Skin Tag • Mucous discharge resulting in itching

  34. Fissure in AnoDiagnosis • Diagnosis often made on history alone • Inspection – gently spread the buttocks and the fissure becomes apparent • Triad of chronic anal fissure • Sentinel pile • Hypertrophied anal papilla • Anal ulcer

  35. Fissure in AnoDifferential Diagnosis • Intersphincteric abscess • Pruritus Ani • Fissure from inflammatory bowel disease • Carcinoma of the anus • Infectious Perianal conditions • Leukemic infiltration

  36. Fissure in AnoCrohn’s Anal Fissures

  37. Acute Fissure in AnoTreatment • Increase dietary fiber • Local anesthetic to prevent spasm • Nitroglycerin or Nifedepine Ointment • Not commercially available • Must be mixed by pharmacist • Warm tub soaks • 4-6 weeks of treatment

  38. Chronic Fissure in AnoSurgical Treatment • Indicated on Chronic non-healing anal fissure and fissure that is refractory to medical therapy • Lateral Internal Sphincterotomy • Forces the muscle to relax • V-Y Anoplasty flap • Allow coverage of fissure with healthy tissue

  39. Hemorrhoids • What are they? • Where are they? • Why do they become symptomatic? • Classification? • How do you treat them? • Can they be avoided?

  40. HemorrhoidsWhat are they? • Specialized highly vascular cushions consisting of discrete masses of thick sub mucosa that contain blood vessels, smooth muscle and connective tissue • Aid in anal continence

  41. HemorrhoidsWhere are they? • Internal Hemorrhoids • 3 major bundles – left lateral, right anterior and right posterior • Above the dentate line • Blood drains into the superior rectal vessels then into the portal circulation • External Hemorrhoids • Below the dentate line • Blood drains through the inferior rectal veins to the pudendal veins on into the iliac veins

  42. HemorrhoidsSymptoms? • Chronic constipation • Diarrhea • Trauma to the hemorrhoids during defecation cause the most common symptoms • Pain – generally not “knife-like” • Itching • Burning • Bleeding

  43. HemorrhoidsClassification- Internal Hemorrhoids • 1st degree – bulge into the lumen • 2nd degree – prolapse with bowel movement but reduce spontaneously • 3rd degree – prolapse spontaneously and require manual reduction • 4th degree – permanently prolapsed hemorrhoids that cannot be reduced

  44. 4th Degree Hemorrhoids

  45. HemorrhoidsTreatment Principles • Thorough physical exam to determine severity and rule out other pathology • Refer for surgical evaluation if white or discolored, firm or fixed • Determine if the problem is internal, external or both • Assess the symptom complex

  46. Treatment • Topical agents: Proctofoam, Anusol HC Analpram, Proctosol cream… • Conservative therapy • Bulk agents – i.e. high fiber • Fruits, vegetables, oat bran, psyllium • Increase water intake • Avoid caffeinated beverages • Avoid prolonged sitting on the commode • Warm tub soaks

  47. TreatmentOffice and Minor Procedures • Rubber band ligation • Performed in the office • Indicated for Grade 1 and 2 internal hemorrhoids • Band is applied through an anoscope at the top of an internal hemorrhoid • Severe perianal sepsis – Classic Triad • Delayed anal pain • Urinary retention • Fever

  48. TreatmentOffice and Minor Procedures • Infrared Photocoagulation • Indicated in 1st degree hemorrhoids • Causes photocoagulation of small vessels • Performed in office or “Hemorrhoid Relief Center” • Minimal pain

  49. Closed HemorrhoidectomyIndication • Hemorrhoids are severely prolapsed and require manual replacement • Patients fail to improve after multiple applications of non-operative treatment • Hemorrhoids are complicated by associated pathology such as ulceration, fissure, fistula, large hypertrophied anal papilla or extensive skin tags

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