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Benign Anorectal Conditions

Benign Anorectal Conditions. Ahmed Badrek-Amoudi FRCS. Anorectal Anatomy. Nerve Supply Sympathetic: Superior hypogastric plexus Parasympathetic: S234 (nerviergentis Pudendal Nerve: Motor and sensory. Arterial Supply Inferior rectal A middle rectal A. Venous drainage

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Benign Anorectal Conditions

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  1. Benign Anorectal Conditions Ahmed Badrek-AmoudiFRCS

  2. Anorectal Anatomy Nerve Supply Sympathetic: Superior hypogastric plexus Parasympathetic: S234 (nerviergentis Pudendal Nerve: Motor and sensory Arterial Supply Inferior rectal A middle rectal A Venous drainage Inferior rectal V middle rectal V 3 hemorrhoidal complexes L lateral R antero-lateral R posterolateral Anal canal Lymphatic drainage Above dentate: Inf. Mesenteric Below dentate: internal iliac Anal verge

  3. HaemorrhoidsBack Ground • They are part of the normal anoderm cushions • They are areas of vascular anastamosis in a supporting stroma of subepithelial smooth muscles. • The contribute 15-20% of the normal resting pressure and feed vital sensory information . • 3 main cushions are found • L lateral • R anterior • R posterior • But can be found anywhere in anus • Prevalence is 4% • Miss labelling by referring physicians and patients is common This combination is only in 19%

  4. HaemorrhoidsPathogensis 3 main processes: 1. Increased venous pressure 2. Weakness in supporting fibromuscular stroma 3. Increased internal sphincter tone Risk Factors

  5. HaemorrhoidsClassification:

  6. HaemorrhoidsClinical assessment

  7. HaemorrhoidsInvestigations: • Lab: CBC / Clotting profile/ Group and save • Proctography: if rectal prolpse is suspected • Colonoscopy: if higher colonic or sinister pathology is suspected

  8. Complications • Ulceration • Thrombosis • Sepsis and abscess formation • Incontinence Thrombosed internal haemorrhoids Thrombosed external haemorrhoids

  9. HaemorrhoidsInternal H. Treatment :

  10. HaemorrhoidsExternal H. Treatment : • If presentation less than 72 hours: • Enucleate under LA or GA • Leave wound open to close by secondary intension • Apply pressure dressing for 24 hours post op • If more than 72 hours: • Conservative measures

  11. Perianal Fistula and Abscess 5% 60% 5% Ischiorectal 20% Intersphincteric suprasphincteric extrasphincteric Trans-sphincteric

  12. Perianal AbscessClinical presentation

  13. Peri-anal FistulaClinical presentation Godsalls law Anterior: drain straight Posterior: drain curved to anorectal midline • Follow 40-60% of perianal abscess and cryptgland infections • Presentation: • External openings • Purulent discharge • Blood • Perianal pain

  14. Perianal AbscessManagement Aim: adequate drainage of abscess preservation of sphincter function * Preop: full lab evaluation *Always perform Examination under GA ( EUA) and obtain a biopsy.

  15. Perianal fistulaManagment Aim: Define anatomy Eliminate tract preservation of sphincter function * Preop: full lab evaluation *Always perform Examination under GA ( EUA) and obtain a biopsy.

  16. Anal Fissure • Linear tears in the anal mucosa exposing the internal sphincter • 90% are posterior • Caused mainly by trauma ( hard Stool). Followed by increased sphincter tone and ischemia. • Other causes: IBD, Ca, Chronic infections

  17. Anal FissureClinical Assessment

  18. Anal FissureTreatment

  19. Pilonidal Sinus Pathogenesis: A sinus tract at natal cleft resulting from: • Blockage of hair follicle • Folliculitis • Abscess followed by sinus formation. • Hair trapping • Foreign body reaction • The sinus tract is cephald Associated with: • Caucasians • Hirsute • Sedentary occupations • Obese • Poor hygeine

  20. Presentation & Treatment • Also found: umbilicus, finger webs, perianal area

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