ANORECTAL
DISEASES
Bernard M. Jaffe, MD
Professor of Surgery, Emeritus
Tulane University School of
Medicine
ANAL CANAL
• Borders- Coccyx
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Ischiorectal Fascia Bilaterally
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Female- Perineal Body; MaleUrethra
• Disorders Common and Generally Benign
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BUT
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Painful and Disabling
• Divided Into Upper and Lower Segments
UPPER VS. LOWER
UPPER
• Above Dentate Line
(Marked by Anal
Valves)
• Pleated, Folded Mucosa
• 12-14 Columns of
Morgagni
• Anal Crypts Between
Columns
• Cuboidal Epithelium
LOWER
• Below Dentate Line
• Smooth Mucosa
• Absent
• Absent
• Squamous Epithelium
ANAL SKIN
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Continuous with Anal Canal
Contains Apocrine Glands
Site of Hydradenitis Suppurativa
Pain Receptors (Not Stretch)
Lesions Drain to Inguinal Nodes
VASCULAR
• Arterial Supply
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Bilateral, Duplicated
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Middle and Inferior Hemorrhoidal
Arteries Off Internal Iliac
• Venous Drainage
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Bilateral, Duplicated
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Internal Iliac Veins to Inferior Vena
Cava
ANAL MUSCULATURE
• One Tubular Structure Inside Another
• Inner- Continuation of Rectal Circular Layer
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Extends 1.5cm Beyond Dentate Line
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Involuntary
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Forms Internal Sphincter
• Outer- Continuous Sheet of Striated Muscle
of Pelvic Floor
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External Sphincter
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Voluntary Control
HEMORRHOIDS
• Abnormal Anal Cushions
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Cushions Contain Blood Vessels,
Smooth Muscle, Elastic and
Connective Tissue
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Left Lateral, Right Anterior,
Right Posterior Positions
• Unknown Causes, Includes Straining
• Common During Pregnancy
EXTERNAL HEMORRHOIDS
• Covered by Anoderm
• Distal to Dentate Line
• Swell, Causing Discomfort, Difficult
Hygiene
• Sever Pain Only with Thrombosis
INTERNAL HEMORROIDS
• Cause Painless Bright Red Bleeding
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Prolapse with Defecation
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Mucus Secretion
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Itching
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Pain is Rare (No Mucosal
Pain Receptors)
HEMORRHOID GRADES
• 1◦ Bleeding
Diet
• 2◦ Prolapse, Bleeding Rubber Band Ligation
• 3◦ Prolapse with
Hemorrhoidectomy or
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Digital Reduction, or Rubber Band
Bleeding
Ligation
• 4.◦ Strangulation
Urgent
Hemorrhoidectomy
OFFICE TREATMENT
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Dietary Management (for All Grades)
Fiber Supplements
Local Hygiene
Avoidance of Straining
Medication to Soften Stool
More Extensive- Rubber Band
Ligation
HEMORRHOIDECTOMY
• Indications
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Failure of Conservative Measures
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Prolapse Requiring Manual Reduction
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Strangulation
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Ulceration
• Commonest Complications
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Bleeding
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Urinary Retention
ANAL FISSURES
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Almost Always Directly Posterior
If Not- STD’s, Crohn’s, Hydradenitis
Associated FindingsSentinal (External) Pile
Enlarged Anal Papilla
Causes Pain, Mild Bleeding
Responds to Sitz Baths, Bulking Agents
ABCESSES
• Originate in Intersphincteric Plane
• Usually From Anal Gland
• If Progress Downward to Skin Causes
Perineal Abcess
• If Progresses to Other Sites
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More Complicated
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Harder to Treat
OTHER SITES OF ABCESS
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Intermuscular- Vertical Tracking
Supralevator- Vertical Tracking
Tough to Diagnose
Ischiorectal- Horizontal Tracking
Horseshoe- Circumferential Tracking
ABCESS TREATMENT
• Drainage is Critical
• Superficial Abcess- Office Drainage
• Attempt to Localize Site of Origin
Within the Anal Lumen
• Needle Localization or CT Imaging
May Be Necessary to Localize
More Complex Abcesses
OPERATIVE DRAINAGE
• OR Required for
• Complex (Horeshoe Abcess)
• High (Supralevator) Abcess
• Immunocompromised
Patients
• Patients With Systemic
Symptoms
FISTULA-IN-ANO
• Complicates Anorectal Sepsis in 25%
• Originates in Dentate Line in Anal Canal
• Presents With Purulent Peri-Anal Drainage
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Punctate Indurated Papule
With Opening
• Inner Opening Identified by Probing at
Dentate Line from Drainage Site
• May Have Multiple External Drainage
Openings
TYPES OF FISTULAS
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Type 1- Intersphincteric
Treated by Fistulotomy
Type 2- Transsphincteric
Type 3- Supersphincteric
Type 4- Extrasphincteric
Latter 3 Treated With Seton
SETON
• Monofilament Nylon or Rubber Band
• Passed Through Fistulous Tract
• Causes Fibrosis and Allows Later (8-12
Weeks) Sphincterotomy Without Loss of
Continence
• Cutting (Progressively Tightening) Seton
Also Acceptable Technique
• Difficult Fistulas- Sliding Flap of Mucosa,
Submucosa, and Muscle to Cover Internal
DIFFICULT FISTULAS
• Sliding Flap of Mucosa, Submucosa,
and Muscle to Cover Internal
Opening
• Injection of Fibrin Glue Into Opening
• Even With Multiple Openings, There
is Generally Only One Internal
Opening
PILONIDAL SINUS
• Midline Sacrocoxxygeal Skin
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Acute Abcess
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Chronic Sinuses
• Rarely Confused With Fistula-in-Ano
• Related to Hair, Penetration of
Granulation Tissue Into Sinuses
• Disease of Young People
• Treated by Excision
CONDYLOMA
ACCUMINATUM
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Peri-Anal Wart
Caused by Human Papilloma Virus
Associated With AIDS, Anal Intercourse
Difficult to Eradicate- Cautery
Podophyllin
Significant Risk of Epidermoid
Carcinoma
HYDRADENITIS SUPPURATIVA
• Chronic Inflammatory Process
• Occurs in Peri-Anal Area and Other HairBearing Areas
• Most Likely Theory- Debris Occludes
Apocrine Gland →Purulence →
Rupture→ Subqu Infection
• Organisms- Strep milleri, Staph aureus,
epidermitis, and hominis
TREATMENT
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Antibiotics
Drainage, Debridement
Fistulotomy (Distal to Dentate Line)
Wide Local Excision With Skin Graft
Difficult to Eradicate
30% Recurrence Rate
Association With Squamous
Carcinoma
CROHN’S DISEASE
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Anorectal Disease in 20%
Jeopardizes Continence 2◦ Inflammation
Causes Fissures, Abcesses, Fistulas
Fistulas Proximal to Dentate Line
Can Be First Manifestation of Disease
Symptoms- Pain, Bleeding, Soilage, Poor
Continence
TREATMENT
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CONSERVATIVE MANAGEMENT
Treat Ileal Crohn’s Dsiease
Sitz Baths, Stool Softeners, Analgesics
Steroids, 6 M-P, Azothiaprine,
Cyclosporine
• Avoid Fistulotomy- If Needed, Use Seton
• Difficult to Manage- Non-Resposive
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Often Extensive
EPIDERMOID CARCINOMA
• Anal mass With Bleeding, Pruritis
• Epidermoid, Basaloid, Cloacogenic,
Mucoepidermoid Types
• <3cm in Size
• 25% Superficial or in Situ
• 71% Deep Penetration, 25%Node
Positive, 6% Distal Metastases
• Increased Frequency in AIDS
TREATMENT
• Superficial Lesions <2cm- Local Excision
• Remainder- Nigro Protocol (Radiation, 5-FU,
Mitomycin)
• Almost All Respond and
TREATMENT
• Superficial Lesions <2cm- Local Excision
• Remainder- Nigro Protocol (Radiation, 5FU, Mitomycin)
• Almost All Respond and Disappear
• APR for Failure of Nigro Protocol
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Contraindication to RT, Chemo
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Deep Invasion
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Aggressive Lesion