Anal Diseases

1. Anal Diseases

2. Levator ani muscle Deep external sphincter and Puborectalis muscle Conjoined longitudinal muscle Subcutaneous external sphincter Anatomy Anorectal ring

3. Arterial supply of the rectum • Superior rectal artery • Middle rectal artery • Inferior rectal artery

4. Venous drainage of the rectum • Internal hemorrhoidal plexus • External hemorrhoidal plexus

5. Sensory Components Neuro pathways • Sympathetic + parasympathetic pathways to internal sphincter (hypogastric) • Somatic to external sphincter (pudendal)

6. Sphincter factors Basal tone • Pressure zone • anal canal 25–120 mmHg • rectum 5 – 20 mmHg • Continuous tone of int. and ext. sphincter increases with increased abdominal pressure

7. Mechanism of Anal Continence Structural considerations • Anorectal angle between rectum and anal canal • Flap valve angle of the anterior rectal mucosa caused by puborectalis causes occlusion • Internal sphincter in continuous tonic state with external sphincter engaged during Vasalva

8. Anal Fissure • Ulcer in the lower portion of the anal canal • Acute / chronic primary / secondary • Sx: anal pain, during and after BM’s

9. Anal Fissure Triade of anal fissure • anal papilla hypertrophy • fissure in ano • sentinel pile

10. Acute Fissure Treatment • inspection, usually increased anal tone can be appreciated on rectal exam if tolerated • cleansing measures typically resolve in 6 weeks without surgical intervention

11. Chronic Fissure • sentinel tag, ulcer,hypertrophied anal papilla • Form because of swelling, edema, and low grade inflammation may go on to fibrosis • Extends from the dentate line to the anal verge

12. Chronic Fissure Teatment • nitroglycerin ointment 0.2% - 0.4% BID • Topical diltiazem (50% resolution at 6 weeks) • Botulinum toxin A injection – 42% recurrence at 42 months – side effects • Surgery: lateral internal sphincterotomy

13. Lateral internal sphincterotomy

14. Secondary anal fissure • Crohn’s disease • Non-midline or abnormal appearing fissure should undergo margin biopsy • Avoid surgery in neutropenic patients – treat with perineal hygine and pain relief

15. Anorectal Abscess

16. Anorectal Abscess • Infection in one of the anal glands • May be asymptomatic or cause severe throbbing pain that resembles a fissure • Abscess should be drained when diagnosed

17. Anorectal Abscess • Sx: severe pain (aggravated by walking, straining) • Swollen mass may be appreciated

18. Anorectal Abscess Treatment • drainage, avoid packing, no abscess typically • Crohn’s disease oral metronidazole or ciprofloxacin seems to have a mitigating effect

19. Fistula • Chronic form of perianal abscess • Evaluation with anoscopy, endoanal ultrasound • Classification

20. Fistula intersphincteric transsphincteric suprasphincteric extraspincteric

21. Goodsall’s rule

22. Fistula Treatment • Unroofing the fistula, eliminating the internal opening, and establishing adequate drainage • Older patients use loosely tied setons to allow for adequate drainage

23. Anal fistulotomy

24. Thread-drawing

25. Hemorrhoids

26. Hemorrhoids • Varices of hemorrhoidal plexus • A-V communication in anal mucosa • Vascular cushions – thick submucosa with blood vessels, smooth muscle, elastic and connective tissue

27. Hemorrhoid Classification • External skin tags • External hemorrhoids (below the dentate line) • Internal hemorrhoids

28. Internal hemorrhoids Treatment • Bulking agents for first and second degree hemorrhoids • Sclerotherapy • Infrared Photocoagulation • Banding 2 – 3 ligations at 4 to 6 week • Hemorrhoidectomy • Stapled Circular Hemorrhoidectomy for prolapsed hemorrhoids

29. Procedure for prolapsed hemorrhoids

30. Circumcise for hemorrhoids

31. Neoplasms of the Anal Canal • Squamous cell carcinoma • Basaloid Carcinoma • Mucoepidermoid Carcinomas • Adenocarcinomas

32. Thank you