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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

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Back to medical school

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  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

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