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Anal Fissures and Haemorrhoids

Anal Fissures and Haemorrhoids. Anal Fissures. Linear tear at the lower part of anal canal. Usually at the posterior midline. Rarely occur at the anterior or lateral aspect. E tiology. Combination of trauma, poor local blood supply. Constipation. Post- haemorrhoidectomy anal stenosis.

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Anal Fissures and Haemorrhoids

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  1. Anal Fissures and Haemorrhoids

  2. Anal Fissures • Linear tear at the lower part of anal canal. • Usually at the posterior midline. Rarely occur at the anterior or lateral aspect.

  3. Etiology • Combination of trauma, poor local blood supply. • Constipation. • Post-haemorrhoidectomy anal stenosis. • Crohn’s disease. • Sexual habits. Pain sphincer spasm trauma constipation

  4. Anal verge to dentate line above. • Acute or chronic

  5. Acute anal fissure • Linear tear at the anal canal below dentate line. • Minimal inflammation, edema of the edges • Duration <2months.

  6. Chronic anal fissure • Inflammation, induration at the edges • Internal sphincter fibres or scar is seen at the floor • Boat shaped ulcer, hypertrophy of the anal valve above. • Sentinel pile- an edematous skin tag at the lower end of the chronic fissure. • Duration >2months.

  7. Clinical features • Symptoms- more common in women, young adults, rarely children • Severe agonising pain, starts during defaecation, lasts for few hours. • Constipation • Minimal fresh bleeding during defaecation. • Scanty mucoid discharge.

  8. Signs- linear tear at the anal verge, sphincter spasm. If chronic, induration at the edges and sentinel pile. • Digital rectal examination- • Examination under anaesthesia-

  9. Treatment • Conservative- laxatives, correction of bowel habits, glyceryltrinitrate gel/ diltiazem gel/ injection of botulinum toxoid( chemical sphincterotomy) • Surgical- Lateral anal sphincterotomy, dorsal anal sphincterotomy, Lord’s controlled anal dilatation, anal advancement flap.

  10. Haemorrhoids • Blood flowing, pile a ball • Dilated veins in relation to the aanus • Occurs isolated or sometimes during pregnancy, portal hypertension, carcinoma rectum, straining at defaecation or micturition, obesity. • Internal/ external/ interno-external

  11. Internal Haemorrhoids • Very common • Dilatation of internal submucous venous plexus with enlarged and displaced anal cushions • They communicate with the external venous plexus

  12. Etiology • Heredity • Morphological- humans and fat old dogs • Anatomical- superior haemorrhoidal vein tributaries are unsupported in the submucosa. They pass through the muscular layer. There are no valves in the portal venous system. • Precipitated by straining to pass stools/ urine

  13. Pathology • Located mainly at 3, 7, 11 o’clock position when the patient is in lithotomy position • Parts- pedicle at the anorectal ring, contains a branch of an artery and vein. Internal haemorrhroid- below the anorectal ring, purple or bright red, variable size. External associated haemorrhoid- between dentate line and anal margin, bluish.

  14. Clinical features • Usually asymptomatic • Bleeding- bright red, during defaecation, intermittent, slight/ drops/ splash of blood • Prolapse- I degree- Nil, II- slight with spontaneous reduction, III- prolapses out and needs to be reduced digitally, IV- remains prolapsed and can not be reduced. • Discharge- scanty mucoid

  15. Pruritis • Painful- only when complicated. Thrombosis, infected, gangrenous

  16. Investigations • Digital rectal examination- only thrombosedhaemorrhoids can be felt. • Proctoscopy- • Sigmoidoscopy-

  17. Complications of haemorrhoids • Profuse bleeding, anemia on long term • Strangulation • Thrombosis- occurs 1-2 hours after strangulation • Ulceration- • Gangrene • Fibrosis • Suppuration, pyelephlebitis( portal pyemia)

  18. Treatment • Regulate bowel habits- ispaghula, senna, polyethylene glycol, liquid paraffin, lactulose, bisacodyl • Local application- local anaesthetic ointment, lubricating agents, topical steroids.

  19. Injection sclerotherapy- for I and II degree haemorrhoids. Given submucosally, at the anorectal ring, 3-5 ml of phenol in almond oil, using Gabriel syringe

  20. Barron’s Banding- II degree haemorroids. Maximum of 2 piles can be treated per sitting. 3 weeks interval between each sitting of treatment.

  21. Cryosurgery- for I and II degree hamorrhoids. Application of liquid nitrogen at -196 C.

  22. Photocoagulation- infrared coagulation.

  23. Surgery- for II, III, IV degree piles and complicated piles. Milligan- Morgan’s open haemorrhoidectomy. Fergusson’s closed haemorrhoidectomy Minimally invasive procedure for haemorrhoids-(MIPH)- stapler haemorrhoidectomy

  24. Complications of Haemorroidectomy • Early- pain, acute urinary retention, reactionary haemorrhage. • Late- secondary haemorrhage, anal stenosis, anal fissure, faecal incontinence

  25. External Haemorrhoids • Group of distinct clinical entities • Thrombosed external haemorrhoid, part of interno-external haemorrhoid, dilated peri-anal venous plexus at the anal verge, sentinel pile.

  26. Thrombosed external haemorrhoid • Peri- anal haematoma. • Subcutaneous clot at the perianal region. • Increased pressure in the perianal venous plexus during straining, coughing leads to extravasation subcutaneously. • Sudden onset of severe painful swelling at the perianal area, tense, tender, usually at the lateral aspect of anus. • Resolve spontaneously after 5 days/rupture/ increase in size/suppurate/ fibrose/ form skin tag.

  27. Treatment • Incision, evacuation of blood clot and excision of skin edges of the incision

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