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Acute Ano-rectal Conditions

Acute Ano-rectal Conditions. Anal Rectal Diseases. Anal Abscess Anal Cancer Anal Fissure Anal Warts Cancer of the Anus Cancer of the Rectum Condyloma Cryptitis Enlarged Papillae Fecal Incontinence Fissure Fistula-in-ano. Hemorrhoids Levator Syndrome Pilonidal Cyst Polyps

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Acute Ano-rectal Conditions

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  1. Acute Ano-rectal Conditions

  2. Anal Rectal Diseases Anal Abscess Anal Cancer Anal Fissure Anal Warts Cancer of the Anus Cancer of the Rectum Condyloma Cryptitis Enlarged Papillae Fecal Incontinence Fissure Fistula-in-ano HemorrhoidsLevator Syndrome Pilonidal Cyst Polyps Procidentia Proctalgia Fugax Proctitis Pruritus Ani Rectal Prolapse Rectocele Warts Venereal

  3. History • Age • Hemorrhoids- • common all ages but are uncommon below the age of 20 years. • Perianal haematomata- • occurs at all ages • Fissure-in-ano-(acute) • quite common in children • Anorectal abscess- • common between the ages of 20 and 50 years. • Pilonidal sinus- • rare before puberty and in people over 40 years.

  4. History • Sex • Hemorrhoids- • common in both sexs • Perianal haematomata- • occurs at all ages • Fissure-in-ano- • common in men • Anorectal abscess- • more common in men • Pilonidal sinus- • more common in men • Prolapse of rectum- • more common in women

  5. History • Principal symptoms of rectal and anal conditions: • Bleeding • Pain • Tenesmus • Change in bowel habit • Change in the stool • Discharge • pruritis

  6. History - Bleeding • Can be fresh or altered • Example of altered is melaena • Black tarry stool • Recognizable blood may appear in four ways: • Mixed with faeces • On the surface of the faeces • Separate from the faeces: after/unrelated to defaecation • On the toilet paper after cleaning

  7. History - Bleeding • Diagnosis of anal conditions which present with rectal bleeding • Bleeding but no pain: • Blood mixed with stool = ca of colon • Blood streaked on stool = ca of rectum • Blood after defaecation = hemorrhoids • Blood and mucus = colitis • Bleeding + pain = fissure or carcinoma of anal canal • The most common causes of rectal bleeding in patients who visit primary care physicians are hemorrhoids, fissures and polyps.

  8. History – Anal pain • careful history focusing on the nature of the pain and its relationship to defaecation • The pattern of pain helps differentiate anal fissure from hemorrhoids and other conditions. (hemorrhoids and rectal cancer are usually not painful) • Anorectal pain that begins gradually and becomes excruciating over a few days with localized are of tenderness is more likely to be • abscess. • A nagging, aching discomfort made worse by defecation could be due to • piles. • An occasional, severe, cramp-like pain deep in the anal canal, that often occur at night, lasting about half an hour • proctalgia fugax. Proctalgia fugax pain is excruciating and may be accompanied by sweating, pallor and tachycardia. Patients experience urgency to defecate, yet pass no stool. • A knife-like pain when you have your bowels open, and which may last for 10–15 minutes afterwards. often described like 'passing glass'. In addition to the pain, some bright red blood on the toilet paper is noticed. • Anal fissure.

  9. History – Anal pain • Diagnosis of anal conditions which present with pain • Pain alone • Fissure ( pain after defaction) • Proctalgia fugax (pain spontaneously at night) • Anorectal abscess • Pain with bleeding • Fissure • Pain with a lump • Perianal haematoma • Anorectal abscess • Pain, lump and bleeding • Prolapsed haemorrhoids/rectum • Carcinoma of the anal canal

  10. Anorectal examination • One of the most important examinations in a patient with abdominal disease. • Still its the least popular segment of the entire physical examination. • Should not be omitted from your examination, especially in middle-aged and older patient, why? • risks missing an asymptomatic carcinooma • Can be done in numerous positions: • Left Lateral (Sims’) position. The usual position when the patient is in bed. Turn patient on to left side with pelvis vertical. Ask patients to draw knees up to chest with buttocks on the side of the couch • The Knee-elbow position. Patient kneeling on couch, resting on elbows, of particular use when palpating the prostate and seminal • The Dorsal Position. This position with the patient lying on the back with right leg flexed is useful when the patient is in severe pain, and movement is contra-indicated. Enables assessment of rectovesical pouch in abdominal emergencies. • Lithotomy. best position for examination but not always available.

  11. Anorectal examination • Things never to be forgotten: • Explain necessity of procedure and reassure the patient • Explain the procedure • Tell the patient that is usually uncomfortable but not painfull Get informed consent • Ensure adequate privacy • Obtain services of chaperone if appropriate • Expose the patient from waist to knee and explain the position of examination. • Equipment: plastic glove + lubricating jelly + good light

  12. Anorectal examination • External inspection: • Piles. • Skin tags (normal, Crohn's, hemorhoids). • Rectal prolapse. • Anal fissure. • Fistula. • Anal warts. • Carcinoma. • Signs of incontinence, diarrhea. • External inspection (straining): • Ask pt. to strain. • Rectal prolapse upon straining. • Hemorrhoid prolapse. • Incontinence. • Ask if straining is painful

  13. Anorectal examination • palpation • Lubricate index finger. • Insert finger slowly, assessing external sphincter tone as enter. • Male: palpate prostate [anterior of rectum]:• Hard nodule (prostate cancer).• Tender (prostatitis). • Female: palpate cervix [anterior of rectum]:• Mass in pouch of Douglas. • Rotate finger, palpating along left, posterior, right walls. • Withdraw finger. • Wipe lubricant off pt. • Ask if was significant pain during examination. 

  14. Anorectal examination • Inspect withdrawn fingertip for: • Blood, melaena • Stool color • Pus • Mucous. • Other examination would be systemically preformed and depends on the case you have e.g swelling such as anorectal abscess or ulcers.

  15. Acute Ano-rectal Conditions

  16. ANORECTAL ABSCESS • An anorectal abscess is a collection of pus in the anal or rectal region • Causes:Infection of an anal fissure (cleft or slit), sexually transmitted infections, and blocked anal glands are common causes of anorectal abscesses • Abscesses may occur in an area that is easily accessible for drainage, or higher in the rectum. • Deep rectal abscesses may be caused by intestinal disorders such as Crohn's disease or diverticulitis.

  17. ANORECTAL ABSCESS • High risk groups include diabetics, immunocompromised patients, people who engage in receptive anal sex, and patients with inflammatory bowel disease. • The male to female ratio is approx. 2:1 • The most common organisms * E.coli (60%) * Staph. aureus (23%) • Common sites of anorectal abscesses

  18. ANORECTAL ABSCESS • Symptoms and signs : * Pain ( the most common symptom) * Swelling (95% of patients) * Discharge (12% of patients) * Fever(18% of patients ) * Constipation (may occur) * Rigors ,sweating and tachycardia • Complications: systemic infection, ,recurrence , scarring and anal fistula formation • TESTS:Rectal examination , Proctosigmoidoscopy • Treatment : * Urgent incision and drainage( the treatment of choice) * Antibiotics

  19. Rectal prolapse • Rectal prolapse is the abnormal movement of the rectal mucosa down to or through the anal opening. Mucosal prolapse Complete rectal prolapse

  20. Rectal prolapse • Mucosal prolapse is more often seen in children below 3 yrs of age following an attack of diarrhoea or whooping cough , and if it occurs in adult is usually associated with haemrrhoids. • Complete rectal prolapse is seen more commonly in elderly women who have a habit of excessive straining during defecation. • Rectal prolapse is often associated with other conditions such as: * Pinworms(Enterobiasis) * Cystic fibrosis * Malnutrition and malabsorption (Celiac disease) * Constipation * Prior trauma to the anus or pelvic area

  21. Rectal prolapse • Symptoms:The main symptom is a protrusion of a reddish mass from the anal opening, especially following a bowel movement. • Treatment : * Treating the underlying condition * In children, Conservative treatment * The rectal mass may be returned to the rectum manually * Surgical correction for complete rectal prolapse • Complications * Constipation * Malnutrition or malabsorption * Other complications of underlying condition

  22. Proctitis • An inflammation of the rectum causing discomfort, bleeding, and occasionally, a discharge of mucus or pus, And the anus may also be involved. • Causes: * Sexually-transmitted diseases(gonorrhea, herpes, Syphilis ,chlamydia, and lymphogranuloma venereum. * Non-sexually transmitted infections( Beta-hemolytic streptococcus , Amoebic dysentry, Bilharzial dysentry) *Autoimmune diseases (Ulcerative colitis and crohn’s disease) * Tuberculous proctitis * AIDS *Radiation Proctitis * noxious agents

  23. Proctitis • Symptoms: • pain, discomfort • rectal bleeding • rectal discharge, pus • stools, bloody • constipation • Tenesmus *Tests: • proctoscopy • sigmoidoscopy • rectal culture

  24. Proctitis • Treatment:treatment of the underlying cause usually cures the problem. Proctitis caused by infection is treated with antibiotics specific for the causative organism. Corticosteroid or mesalamine suppositories may relieve symptoms in Crohn's disease or ulcerative colitis.

  25. Benign tumours of the rectum(POLYPS) • A polyp is a lesion that projects into the lumen • Polyps are commonly found in vascular organs • Polyps bleed easily • The rectum and sigmoid colon are common sites of polyps • Symptoms and signs of polyps * passage of blood and mucus PR * Rarely obstruction or intussusception

  26. Types of Polyps • Juvenile Polyps • Commonest form of polyps in children • Are red pedunculated spheres lesions • Can occur throughout large bowel but are most common in the rectum • Usually present before 12 years • Present with Prolapsing lump or rectal bleeding • Have little malignant potential • Treated by local endoscopic resection

  27. Adenomatous Polyps • Are pedunculated lesions • Mainly occur in the rectum and sigmoid colon • Are often asymptomatic but may produce anaemia from chronic occult bleeding • May give rise to crampy pain • May secrete mucus • Have malignant potential • Treated by colonoscopic polypectomy

  28. Villous Papillomas • Are flat, sessile lesions within the rectum • Secrete copious amount of mucus producing spurious diarrhoea • Present with hypokalemia • Significant risk of malignant change • Treated by transanal excision of complete lesion • If lesion is extensive, mucosal proctectomy and coloanal anastomosis should be done

  29. Familial Polyposis • Is an autosomal dominant syndrome diagnosed when a patient has more than 100 adenomatous polyps • Due to mutation on long arm of chromosome 5 • May be asymptomatic but bleeding,, abdominal pain and diarrhoea are all likely symptoms • The risk of devoloping carcinoma is virtually 100% within 15 years • The most appropriate treatment is panproctocolectomy with ileal pouch-anal anastomosis

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