Benign Anal and Colonic Disorders

1. Benign Anal and Colonic Disorders Bruce George John Radcliffe Hospital 16-6-04

2. Anatomy revision

3. Factors contributing to normal bowel function Colonic transit CNS co-ordination Sensation Mechanical barrier Ability to evacuate

4. Anal pain Bleeding Discharge Swelling Itching Leakage Urgency Symptoms of anal pathology

5. Examination General Abdominal Inspection at rest soiling, excoriation, scars, patulous, guttering squeeze straining perineal descent Rectal examination Proctoscopy and sigmoidoscopy

6. Investigations Anal canal pressures Sensation Pudendal nerve latency Endoanal ultrasound Rarely: MRI anorectum MRI spine ambulatory pressures

7. Causes of Anal Pain PILES (thrombosed) ABSCESS FISSURE

8. ANAL FISSURE

9. Linear ulcer below dentate line midline (if multiple/lateral think of Crohn’s disease) Anal pain During + after defaecation Bleeding Bright red/spotting Anal fissure

10. Most acute fissures heal spontaneously Assisted by bulking laxatives Non-constipating analgaesica ?lignocaine gel Chronic fissures associated with internal sphincter hypertonia Above + reduction in IAS tone Management

11. Surgical Anal stretch Internal sphincterotomy Pharmacological GTN botulinum Methods of reducing IAS tone

12. Acute and chronic manifestations of the same disease proess ACUTE = ABSCESS CHRONIC = FISTULA Anal abscess and fistula

13. Perianal abscessacute infection originating in anal gland

14. Natural history of perianal abscess • Drainage via anal gland • resolution • Drainage via abnormal route • Resolution of abscess • Creation of fistula • Intersphincteric • Trans-sphincteric • others

17. Abscess severe anal pain Fistula recurrent discharge cycles of pain/discharge Symptoms

19. not

20. Traditional treatment of anal fistula

26. piles Swollen or fragile anal cushions

27. INJECTION SCLEROTHERAPY • First and Second Degree where bleeding is principle symptom. • Irritant sclerosant solution (phenol in oil) injected into submucosa proximal to each haemorrhoidal plexus • Simple, safe , painless • Complications related to incorrect application. • Long-term success rate - sparsely reported.

28. RUBBER BAND LIGATION • I / II Degree, some III degree • Barron ligator applies two bands to base of pile. • ? Number of bundles banded per session. • ? Success Rate: 33% relapse in 5 years • Complications • Pain • Bleeding • Postbanding Pelvic Sepsis

30. Notoriously painful

31. Obviously GI COBH, blood PR, distension, abdominal pain, tenesmus Involvement of adjacent structures Fistula to bladder, vagina, skin Back, psoas irritation Extra-colonic manifestations Iritis, erythema nodosum, arthriris, sclerosing cholangitis Symptoms of colonic disease

32. Examination • General examination • Abdominal examination • Rectal examination

33. Proctoscopy and rigid sigmoidoscopy Stool examination Flexible sigmoidoscopy Colonoscopy Barium enema CT colon Investigations

34. Rectal bleeding Change in bowel habit The elderly/frail Suspected diverticular disease Suspected inflammatory bowel disease Who needs which investigations?

35. 25 year old BRRB, associated with straining 50 year old BRRB and mucus 75 year old DRRB

36. 25 year old bloody diarrhoea for 3 months 50 year old constipation and bloating intermittently for 12 months 75 year old COBH and iron deficiency anaemia Change in bowel habit

37. 75 year old increased frequency of bowel movements and LIF pain for 3 months 80 year old change in bowel habit for 3 months Change of bowel habit

38. Everyone: History and examination including PR Proctoscopy and rigid sigmoidoscopy Rectal bleeding: Rigid/flexi/colonoscopy (safety margin) Change in bowel habit: Usually barium enema Colonoscopy if suspected IBD or high index suspicion cancer Top and tail if iron deficiency anaemia CT colon if frail Stool cultures if diarrhoea Summary

39. Diverticular disease Crohn’s disease Ulcerative colitis The common benign colonic diseases

40. Diverticular disease Disease of modern elderly Western population Lack of dietary fibre roller milling of wheat flour geographical differences in fibre intake Oxford vegetarian study

41. Spectrum of diverticular disease • Diverticulosis • Asymptomatic • symptomatic • Diverticulitis • Uncomplicated • Acute complicated (hinchey 1-4) • Fistulating • stricturing • Diverticular haemorrhage

42. Diverticulosis Make diagnosis accurately High fibre diet Treatment of Diverticular Disease

43. Acute uncomplicated and Hinchey 1-2 Aim to avoid acute surgery Intravenous fluids and antibiotics Radiological drainage of contained abscess(es) When acute episode settled: Visualise colon (DCBE/colonoscopy) Consider surgery Treatment of diverticulitis

44. Hinchey 3-4 Resuscitation and emergency surgery Fistula Surgery soon Stricture Complete obstruction: urgent surgery Partial obstruction: surgery soon Treatment of diverticulitis

45. Chronic inflammatory bowel disease 40% terminal ileum/caecum 30% small bowel 30% colonic 20-80% anal disease, especially in association with rectal or colonic inflammation Crohn’s disease

46. Crohn’s disease

47. Crohn’s disease Skip lesions Cobblestone appearance, fissures, ulceration Transmural inflammation

48. Medical Steroids 5-ASA drugs Immunosuppressants (azathioprine) Nutritional Enteral TPN Surgical Treatment of Crohn’s disease

49. Failure of medical therapy Chronic complications Abscess, fistula, obstruction Dangerous acute complications Perforation, dilatation, haemorrhage Risk of developing malignancy Indications for surgery for Crohn’s colitis

50. Ulcerative Colitis • Chronic inflammatory condition of large bowel • Dentate line extending proximally in continuous fashion • Disease of mucosa only