Common Anorectal
Diseases
Lecturer:
Professor Saleh M. AlSalamah FRCS
Professor of Surgery & Consultant General
and Laparoscopic Surgeon
College of Medicine, King Saud University,
Riyadh, KSA.
References
 Clinical Surgery by Michael M. Henry
 Bailey and Love’s Short Practice of
Surgery
 Essential of General Surgery by Peter F.
Lawrence
Objectives
 At the end of this presentation students will
be able to:
 Understand the surgical anatomy of the anal canal.
 Classification, pathogenesis and management of
hemorrhoids.
 Pathogenesis, presentation and management of anal
fissure.
 Presentation. Classification and management of
perianal abscess.
 Classification and management of anal fistula.
 Pathogenesis, presentation and management of anal
carcinoma.
Anorectal Diseases
 Overview
 Surgical Anatomy
 Examination of the Anus
 Common Anal Conditions
Overview
 Anal and perianal disorders makeup about
20% of all outpatient Surgical referrals.
 These conditions are extremely distressing
and embarrassing patient often put up
with symptoms for long time, before
seeking medical care.
Common symptoms
 Anal bleeding
 Anal pain and discomfort
 Perianal itching and irritation
 Something coming down
 perianal discharge
Surgical Anatomy
 The anal canal 1.5” (4 cm) long and is
directed downward and backward from the
rectum to end at the anal orifice.
 The mid of anal canal represents the
junction between endoderm and ectoderm
Surgical Anatomy
 The lower ½ is lined by squamous
epithelium and the upper ½ by columnar
epithelium so carcinoma of the upper ½ is
adenocarcinoma. Where as that arising
from the lower part is squamous tumour.
Surgical Anatomy
 The blood supply of upper ½ of the anal
canal is from the superior rectal vessels.
Where as that of the lower ½ is supply of
the surrounding anal skin the inferior
rectal vessels which derives from the
internal pudendal ultimately from the
internal iliac vessels.
Surgical Anatomy
 The lymphatic above the mucocutaneous
junction drain along the superior rectal
vessels to the lumbar lymph nodes, where
as below this line drainage is to the
inguinal lymph nodes.
Surgical Anatomy
 The nerve supply to the upper ½ via
autonomic plexus and the lower ½ is
supplied by the somatic inferior rectal
nerves terminal branch of the pudendal
nerve. So the lower ½ is sensitive to the
prick needle.
Anal Sphincter
 The internal anal sphincter of in voluntary
muscle, which is the continuation of the
circular muscles of the rectum.
 The external sphincter of the voluntary
muscles, which surrounds the internal
sphincter and comprises 3 parts
(formerly)
 subcutaneous the lower most portion of the
external sphincter
 superficial part
 deep part
Common Anal Conditions
 Haemorrhoids
 Pruritus ani
 Perianal abscess
 Anal fissure
 Anal fistula
 Rectal prolapse
 Anal in continence
 Non malignant strictures
 Anal neoplasms
Examination of Anus
 This requires careful attention to circumstances
(couch, light, gloves). The Sims (left lateral
position) is satisfactory. The examination proceed
by;
 inspection
 digital examination with index finger
 proctoscopy
 sigmoidoscopy
Hemorrhoids
 Piles may be internal or external according
to whether they are internal or external to
anal orifice.
 The internal Haemorrhoids:
 They are dilation of the superior
haemorrhoidal veins above the denate line
each pile consists of mass of dilated vein,
artery, some connective tissue and
mucosal investment.
Hemorrhoids
 The location of piles, right anterior, right
posterior and left lateral situated
respectively 11, 7, 3 o’clock with patient
in the lithotomy position, these are give
daughter piles.
Etiology
Primary Causes:
Hereditary factors e.g, structural
weakness of the vein.
Anatomical factors.
Partial congestion.
Chronic constipation.
Sphincteric relaxation.
Etiology
Secondary Causes:

pregnancy
 venous obstruction
 straining on micturation
 venous congestion
 carcinoma of the rectum
Clinical features
 Bleeding at defecation
 Prolapse
 Discharge with pruritus ani
 Pain
 Thrombosed piles
Assessment and Diagnosis
 Careful history
 Abdominal Examination
 Anorectal Examination
 Investigation e.g., proctoscopy
Complications
 Profuse haemorrhage
 Acute thrombosis
Treatment
Treatment

Injection treatment
 Gabriel syringe is filled with sclerosant 5% phenol with
almond oil
 Barron’s rubber banding
 Cryosurgery
 Co2 Laser
 Lord’s manual dilation
Hemorrhoidectomy
Stapled Hemorrhoidectomy
External Hemorrhoids
Perianal Hematoma
 Due to rupture of dilated anal vein as
result of sever straining.
 Sudden onset of painful lump at the anus.
 Swelling tense & tender, bluish in colour
covered with smooth shining skin.
External Hemorrhoids
Treatment
 Evacuation if the patient come within
48hours
 If
patient come late conservative
treatment.
 If untreated the haematoma undergoes:
 resolution
 ulceration
 suppuration to forms in abscess
 fibrosis which give rise to skin tag.
Perianal Abscess
 The infection usually starts in one of the
crypts of Morgagni and extends along the
related anal gland to the intersphincteric
plane where it forms as abscess.
 Soon it tracks in various directions to
produce different types of abscesses .
Types of Abscess
 Perianal abscess (60%)
 Ischiorectal abscess (30%)
 Sub mucous abscess (5%)
 Pelvirectal abscess
Perianal Abscess
 Patient with recurrent anorectal abscess
always consider associated underlying
diseases such as Crohn’s, UC, rectal
cancer and active TB.
Perianal Abscess
 Symptoms
 Acute pain
 High fever
 Signs
 Swelling
 Tenderness with induration
 Treatment
 Incision and drainage and covered by antibiotics.
Perianal Abscess
Fistula in ano
 Defined as track lined by granulation
tissues, which connects deeply in the anal
canal or rectum and superficially on the
skin around the anus.
 It usually result from an anorectal
abscess.
Fistula in ano
 Anal fistulas have well recognized
association with crohn’s disease, UC, TB,
colloid carcinoma of the rectum and
lympho granuloma venercum.
Types of Anal Fistulas
 According to whether their natural opening is
below or above the anorectal ring
 Low level e.g., subcutaneous, low anal, sub
mucous.
 High level – open into anal canal at or above
the anorectal ring e.g., high anal, pelvirectal
Park’s Classification
 Inter sphincteric (70%) low level
 Trans-sphincteric (25%) high
anal fistula
level anal fistula
 Supra sphincteric fistulae (4%).
 Extra sphincteric (1%) rare type include the tract
passes outside
all sphincter muscles to open in
the rectum.
Good Sall's Rule
 Fistulas with external
opening in relation to
the anterior ½ of the
anus
tend to be direct
type.
Clinical features
 Persistent discharge which irritates the
skin and causes discomfort at the anus
may be associated with pain.
 External opening may be seen with
palpation the tracks is often palpable as
cord.
Investigations
 Proctoscopy
 Radiology
 Biopsy
Surgery
Fistulectomy
Always sent track for biopsy.
Seton placement
Anal Fissure
 Defined as longitudinal tear in the mucosa
and skin of the anal canal.
 Commonly posterior midline more
common in female than male.
Anal Fissure
 Lateral fissures are so rare there presence
suggest specific lesions such as, Crohn’s
disease, UC, TB or malignancy.
Etiology
 Tearing of the anal lining by over distension
of
the anal canal during passage of large scybalous
mass (stool).
 Tearing of anal valve or fibrous polyps.
 Laceration of the anal canal by sharp FB.
 Excessive straining during child birth.
Anal Fissure
 The acute anal fissure if not treated
becomes chronic anal fissures. As result
secondary pathological changes may
occurs:
 Chronicity
 A “sentinel” pile
 Hypertrophied anal papilla
 Contracture of the anus
 Suppuration
Clinical Features
 Pain during and after defecation.
 Constipation
 Bleeding
 Discharge
Findings
 Fissure or ulcer distal to dentate line.
 Sentinel Tag
 Hypertrophied papilla.
 Spasms of the internal sphincter
Treatment
 Conservative Treatment
 Stool softeners (laxative)
 Sitz baths (10 – 15 mins.)
 Ointments & Suppository
Treatment
 Surgical Treatment
 Dilation under anaesthesia (Anal Stretch)
 Fissurectomy and dorsal sphincterotomy
 Lateral internal sphincterotomy
Anorectal Tumours
 Benign tumours
 Epithelial Tumours
Anal warts (virus)
Juvenile polyp
Adenomatous polyps
Villous papilloma
Familial polyposis
Pseudo polyps
Endometrioma
Anorectal Tumours
 Connective Tissue Tumours
 Fibrous polyp
 Lipoma
 Myoma
 Haemangioma
 Benign Lymphoma
Malignant Tumours of the Anal Canal
 The lesion is usually squamous cell
carcinoma.
 Rarely adenocarcinoma, malignant
melanoma or basal cell carcinoma.
Squamous cell carcinoma
 5% of all anorectal malignancies. Arising from the
stratified squamous epithelium of the lower ½ of
the anal canal.
 It is disease of elderly.
 Squamous cell carcinoma more common in males.
 The aetiology of anal carcinoma unknown but
chronic irritation or infection may be predisposing
factors.
Clinical Features
 Localized ulcer or raised growth with
irregular ulcerated surface.
 History of bleeding.
 History of pain with discomfort.
 Tenesmus with incontinence.
 Discharge.
Examination
 On palpation squamous carcinoma feels hard and
woody due to invasion of perianal tissues.
 P/R examination may prove impossible because of
stenosis
or discomfort.
 Inguinal LN are examined
carefully as they
receive lymph from the lower anal canal and
perianal region and may be the site of metastasis.
Treatment
 Above the pectinate line
 Abdomino perineal excision
 Below the pertinate line
 local excision.
 If inguinal LN metastasis present should be
removed by block dissection.
Treatment
 Late cases
 Palliative colostomy.
 Radiotherapy.
Rare Malignant Anal Tumours
 Adenocarcinoma
 Basal cell carcinoma
 Malignant melanoma
Benign strictures
 Stricture of the anus and rectum may be:
 Congenital
 Postoperative
 Inflammatory
Clinical features
 Progressive difficulty in defecation
 In cases of inflammatory strictures
 Bleeding
 Discharge
 Tenesmus
 Late cases subacute intestinal obstruction
Diagnosis
 Rectal examination reveals
the location
type and degree of the stenosis.
 Proctoscopy
 Biopsy
Treatment
 Dilation
 Superficial external
proctotomy
Thanks