1 / 54

Back to medical school

Back to medical school. -anorectal disorders. Ian Botterill, Dept Colorectal Surgery Leeds General Infirmary. Wide variety of pathologies. congenital / acquired benign / malignant traumatic infective / inflammatory gender / age related. Common symptoms of ano-rectal disorders. bleeding

chaz
Download Presentation

Back to medical school

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Back to medical school -anorectal disorders Ian Botterill, Dept Colorectal Surgery Leeds General Infirmary

  2. Wide variety of pathologies • congenital / acquired • benign / malignant • traumatic • infective / inflammatory • gender / age related

  3. Common symptoms of ano-rectal disorders • bleeding • anal pain • itch • faecal leakage / hygiene problems • swelling • discharge

  4. Examination • abdomen • groins (lymph nodes) • dermatoses

  5. chaperoned relaxed patient left lateral good light knee elbow position use pt’s hand to elevate right buttock +/- anoscopy in 1y care Ano-rectal examination

  6. External appearance -skin condition -swellings -soiling / discharge -perineal descent -scars Digital examination -sphincter tone -squeeze pressure -cervix / prostate -coccyx -retrorectal space -rectocoele Ano-rectal examination

  7. Anatomy

  8. Symptoms: - anal canal bleeding, pruritus, swelling, pain Haemorrhoids

  9. Haemorrhoids • Classification - 1y: bleed, do not prolapse - 2y: prolapse & reduce spontaeously - 3y: prolapse & require manual reduction - 4y: prolase, not reducible

  10. Cause of haemorrhoidal problems • altered bowel habit • raised intra-abdominal pressure • straining

  11. Treatment of haemorrhoids • Diet -five helpings fibre / d • Out-patient -injection sclerotherapy -banding -photocoagulation

  12. Surgical treatment • For 3rd / 4th degree haemorrhoids • Open haemorrhoidectomy • Closed haemorrhoidectomy • Ligasure haemorrhoidectomy • Stapled haemorrhoidopexy (PPH)

  13. Results of haemorrhoidectomy • >90% daycase • least initial pain -stapled haemorrhoidopexy -Ligasure haemorrhoiodectomy • quickest return to work: -stapled haemorrhoidopexy -Ligasure haemorrhoidectomy • most costly: PPH / ligasure • lowest recurrence (prolapse) ; conventional

  14. Complications of haemorrhoidectomy • Local - stenosis - faecal leakage - recurence - bleeding - retention of urine • severe perineal sepsis (esp IDDM & immunosuppressed)

  15. Painful prolapsed haemorrhoids • natural history (worst pain days ~ 3-7, then settles) • most resolve with conservative Rx - lactulose / topical anaesthetic creams / ice / paracetamol & NSAIDs / relief of anal spasm (GTN or diltiazem) - failure to resolve > haemorrhoidectomy - refer gangrenous or those that fail to settle • interval haemorrhoidectomy if still problematic

  16. Anal skin tags Sx: anal swelling / hygiene problems Diagnosis: perineal examination alone Differential: Crohn’s disease / anal warts Rx: reassurance / excision

  17. Rectal mucosal prolapse & full thickness rectal prolapse

  18. Rectal mucosal prolapse • result of straining • associated with pruritus ani / mucous discharge • diagnosis @ anoscopy • Rx - dietary correction - advised to avoid straining at stool - injection sclerotherapy

  19. Ano-rectal sepsis Sx: perineal pain (throbbing), possible prior history of similar Exam: tender fluctuant mass +/- discharge, may be toxic Beware: diabetics (risk of rapidly progressive infection & Fournier’s gangrene) skin necrosis (possible Fournier’s gangrene) anal spasm & throbbing pain (inter-sphincteric abscess) Treatment: I&D

  20. Fistula in ano ~ 30-40% of all perineal sepsis once drained goes on to develop a fistula ~ 80-90% of perineal sepsis that yielded enteric organisms will develop a fistula

  21. Fistula in ano • 95% cryptoglandular - ie origin in ano-rectal crypts at dentate line • 5% rarities - Crohn’s - TB - hidradenitis suppurativa - traumatic - malignancy - complicated diverticular disease - radiation - anastomotic leakage

  22. Classification Inter-sphincteric 70% Trans-sphincteric 25% Supra-sphincteric ~5% Extra-sphincteric <1% Simple v. complex ‘Complex’: -branching tracts / 2y tracts -associated abscess -associated pathology

  23. Goodsall’s rule External opening posterior to 3-9 oclock position open in posterior midline of the anal canal External opening anterior to 3-9 oclock position open radially in the anal canal ~80-90% accurate

  24. Management of fistula in ano Strike a balance between -cure of fistula -prevention of further anorectal abscess -preservation of continence

  25. Management of fistula in ano • Divide tissues overlying track ( to allow healing by 2y intent) - lay open - cutting seton • Occlude internal opening & provide external drainage - anal fistula plug - rectal or anal advancement flap • Prevention of further ano-rectal sepsis - draining seton

  26. Anal fissure • ‘focal linear deficiency of anal mucosa’ • posterior > anterior • acute v. chronic -chronic: IAS exposed , > 6/52, keratinisation • simple v. complex

  27. Anal fissure

  28. Anal fissure management • stool softeners • dietary advice • topical LA • chemical sphincterotomy -topical -injected • surgical sphincterotomy

  29. Anal fissure surgery through the ages • anal stretch • lateral sphincterotomy • chemical sphincterotomy - topical - injectable

  30. Anal fissure treatment • GTN 40-50% successful s/e: severe headaches • Diltiazem 60-80% successful s/e: nil generally • Botox 60-90% successful s/e transient minor leakage • Sphincterotomy 98% successful s/e 2% passive leakage

  31. Proctitis • Biopsy mandatory (with exception of prior prosate / cervical brachytherapy) • UC / Crohn’s / indeterminate / infective • Stool culture • Biopsy prior to starting suppositories • Suppositories often preferable to oral therapy

  32. Pilonidal sinus / & abscess Abscess often deep-seated – do not respond to antibiotics

  33. Pilonidal sinus disease

  34. Z plasty Uli Szymanovski Developed ‘Z’ plasty wound closure

  35. Rhomboid flap Healing by 1y intention ~90% of time as with Z plasty

  36. Healing by 2y intent

  37. Healing using Vac Therapy

  38. Perianal haematoma • Thromobosis of superficial haemorrhoidal veins • Discrete circular lump at / beyond anal verge • Incise & drain

  39. Pruritus ani Night > day Rule out coexistent dermatoses / renal failure / liver disease If fungal disease suspected > skin scrapings Ano-rectal examination & proctoscopy. Treat ano-rectal pathology (haemorrhoids / faecal incontinence / anal tags etc).

  40. Pruritus treatment • Avoid synthetic / tight underwear • Avoid perfumed soaps etc • Avoid scratching • Use hairdryer to dry skin • Avoid steroid creams • Treat anal pathology / diarrhoea • Dermatology involvement • Methylene blue injections > ~80% successful - s/e occasional cellulitis / ulcer / incontinence

  41. Faecal incontinence - understand continence first! • Brain / higher centres • Spinal cord • Reflex arcs • Pudendal nerves • Ano-rectal sensation ‘sampling’ • Stool consistency • Rectal compliance • Anal sphincter complex

  42. Faecal incontinence • Causation • Obstetric injury (8-30% sphincter injury rate at childbirth) • Post-surgical • Faecal impaction • Neuropathy / MS / Parkinson’s • Poor mobility / impaired cognition • Diarrhoea • IBS / rectal non-compliance

  43. Assessment of faecal incontinence • History • Examination • Endoanal USS (sphincter injury) • Anorectal manometry (rest & squeeze strength) • Pudendal nerve terminal latency (sensation)

  44. Assessment of incontinence • Cleveland clinic score - severity of soiling - frequency of soiling - use of pads - lifestyle disruption • History of back injury / neurolgical disorder • Urinary incontinence • Saddle anaesthesia

  45. Treatment incontinence • dietary measures • treat diarrhoea / impaction / IBS • non-operative - collagen injections - anal plug • sacral nerve stimulation • sphincter repair • artificial sphincters • graciloplasty

  46. Anal stenosis • Post-surgical • Cancer • Crohn’s • Previous chronic anal fissure • Radiation • Systemic sclerosis • Need EUA to assess all these

  47. Anal cancer Sx: itch, bleeding, pain (if below dentate line), swelling, ulcer, groin node Exam: hard, irregular, friable area. Groin nodes possible. ? Coexists with anal warts Differential: haemorrhoids, anal fissure, anal warts, STD Diagnosis: EUA & biopsy

  48. Anal cancer-treatment • Chemo-radiotherapy • Ongoing perineal surveillance • Average local control ~ 70% • Average cure ~ 70% • Salvage surgery for recurrence - APER with rectus flap to perineum • Rarely is local excision alone sufficient

  49. Hidradenitis suppurativa Superficial fistulating condition ass’d with chronic skin sepsis Axillae > groins > perineum Clinical diagnosis (+/- biopsy) – typically have disease elsewhere Rx: drain sepsis / rotating antibiotics / infliximab / stop smokng

  50. Anal papillae Sx: nil (asymptomatic finding typically) Diagnosis: at anoscopy Biopsy: rarely required Treatment: leave alone

More Related