anorectal diseases

Common Anorectal
Professor Saleh M. AlSalamah FRCS
Professor of Surgery & Consultant General
and Laparoscopic Surgeon
College of Medicine, King Saud University,
Riyadh, KSA.
 Clinical Surgery by Michael M. Henry
 Bailey and Love’s Short Practice of
 Essential of General Surgery by Peter F.
 At the end of this presentation students will
be able to:
 Understand the surgical anatomy of the anal canal.
 Classification, pathogenesis and management of
 Pathogenesis, presentation and management of anal
 Presentation. Classification and management of
perianal abscess.
 Classification and management of anal fistula.
 Pathogenesis, presentation and management of anal
Anorectal Diseases
 Overview
 Surgical Anatomy
 Congenital Abnormalities
 Examination of the Anus
 Common Anal Conditions
 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
 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
Congenital Abnormalities
 High abnormality more serious because
it is associated with poor development of
the pelvic muscles.
 Low abnormality which is simply to
treat:These abnormalities should be
diagnosed at birth is the standard physical
examination of the new born infant. If the
diagnosis missed the infant developed
symptoms and signs of large bowel
Congenital Abnormalities
 High abnormalities:
 The rectum stops short of the pelvic floor
and the anal canal is absent.
 Low abnormalities:
 The abnormality is usually either ectopic
or covered anus.
 On physical examination:
 If the baby fail to produce meconium stool
in the first few hours of life.
 Investigation: urine for meconium, if no
meconium is visible the site of the anus
marked with metal and x-ray taken for the
baby up side down so gas shadow may
helps to show the distal point of bowel
 Need early and vigorous treatment in
 Low abnormalities: should be treat by
“cutback type operation” followed by
regular digital dilatation by the mother.
 High abnormalities: should be treated
by colostomy in the 1st few days followed
by some sort “pull through operation” at
the age of one year.
Examination of Anus
 This requires careful attention to circumstances
(couch, light, gloves). The Sims (left lateral
position) is satisfactory. The examination proceed
 inspection
 digital examination with index finger
 proctoscopy
 sigmoidoscopy
 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.
 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.
Primary Causes:
Hereditary factors e.g, structural
weakness of the vein.
Anatomical factors.
Partial congestion.
Chronic constipation.
Sphincteric relaxation.
Secondary Causes:
 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
 Profuse haemorrhage
 Acute thrombosis
Injection treatment
 Gabriel syringe is filled with sclerosant 5% phenol with
almond oil
 Barron’s rubber banding
 Cryosurgery
 Co2 Laser
 Lord’s manual dilation
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
 Evacuation if the patient come within
 If
patient come late conservative
 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
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
 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
tend to be direct
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
 Proctoscopy
 Radiology
 Biopsy
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.
 Tearing of the anal lining by over distension
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
 Chronicity
 A “sentinel” pile
 Hypertrophied anal papilla
 Contracture of the anus
 Suppuration
Clinical Features
 Pain during and after defecation.
 Constipation
 Bleeding
 Discharge
 Fissure or ulcer distal to dentate line.
 Sentinel Tag
 Hypertrophied papilla.
 Spasms of the internal sphincter
 Conservative Treatment
 Stool softeners (laxative)
 Sitz baths (10 – 15 mins.)
 Ointments & Suppository
 Surgical Treatment
 Dilation under anaesthesia (Anal Stretch)
 Fissurectomy and dorsal sphincterotomy
 Lateral internal sphincterotomy
Rectal Prolapse
 Rectal prolapse occurs most often at
of age.
 Children between 1-5 years of age and
elderly people.
 More common in female than male.
Rectal Prolapse
 Prolapse of the rectum mainly two types:
 Partial or incomplete prolapse when
the mucous membrane lining the anal
canal protrudes through the anus only.
 Complete prolapse in which the whole
thickness of
the bowel protrudes
through the anus.
 In children:
 The vertical straight course of the rectum.
 Reduction of supporting fat in the
ischiorectal fossa.
 Straining at stool.
 Chronic cough.
 Partial prolapse:
Advance degree of prolapsing piles.
Loss of sphincter tone.
Straining from urethral obstruction.
Operations for fistula.
 Complete prolapse:
generally regarded as sliding hernia of
the recto vesical or recto vaginal pouch
due to stretching of the levator ani
from pregnancy, obesity.
Clinical Features
 Prolapse is first noted during defecation.
 Discomfort during defecation.
 Bleeding.
 Mucous discharge.
 Bowel habit irregular and may lead to
Complications of rectal prolapse
 Irreducibility
 Infection
 Ulceration
 Severe haemorrhage from one of the mucosal vein
 Thrombosis and obstruction of the venous returns
leading to oedema
 Irreducibility and gangrene
 In children
 the prolapse tends to disappear spontaneously by the
age of 5 years. So conservative measures are
 Conservative treatment: constipation and
straining at stool are avoided and the buttocks may
be strapped together to discourage prolapse during
 Perirectal injection of alcohol/phenol may be used to
fix the lax mucosa to underlying tissue.
Prolapse in adults
 Partial prolapse
 Provided sphincter tone is satisfactory can be
treated by ligature excision of prolapsed
 Injections of 5% phenol in oil in submucosa.
15ml total.
 Electrical stimulation with sphincteric exercises.
Prolapse in adults
 Complete prolapse:
 Surgery always necessary, none are ideal.
Thiersch’s operation
Rectopexy (lock haurt)
Rectosigmoidectomy (Mikulicz’s op.)
Ivalon sponge rectopexy (Well’s op.)
Ripstein operation
Low anterior resection (minor)
Anal Incontinence
Normal anal continence depends on an
intact spinal cord reflex acting on an
adequate sphincteric mechanism under
cortical inhibitory control.
Causes of Incontinence
 Congenital
malformations of the
anus in which the
sphincter is partially or
completely lacking.
 Trauma. e.g accidental
injury, obstetrical
tears or operative
Causes of Incontinence
 Medical conditions e.g., mental deficiency,
senility and spinal cord lesions.
 Neurological and physiological diseases
e.g. spina bifida, spinal tumours and
 Anorectal disease e.g. rectal prolapsed,
piles, chronic inflammatory bowel disease,
faecal impaction, destruction as carcinoma
of anus.
Clinical Features
 The following are the clinical types:
 True incontinence
 Partial incontinence
 Overflow incontinence
 There is no satisfactory treatment for many
causes of incontinence.
 Conservative measure: satisfactory for minor
degree of incontinence e.g., anorectal lesion,
faecal impaction and the sphincter tone improved
by daily exercises.
 Operative treatment: this depend on the causes of
 Thiersch’s operation
 Obstetrical injury (coloperincorrhaphy)
 Sphincteroplasty in cases of traumatic
postoperative incontinence.
 Sphincter reefing
 Colostomy
Anorectal Tumours
 Benign tumours
 Epithelial Tumours
Anal warts (virus)
Juvenile polyp
Adenomatous polyps
Villous papilloma
Familial polyposis
Pseudo polyps
Anorectal Tumours
 Connective Tissue Tumours
 Fibrous polyp
 Lipoma
 Myoma
 Haemangioma
 Benign Lymphoma
Malignant Tumours of the Anal Canal
 The lesion is usually squamous cell
 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
Clinical Features
 Localized ulcer or raised growth with
irregular ulcerated surface.
 History of bleeding.
 History of pain with discomfort.
 Tenesmus with incontinence.
 Discharge.
 On palpation squamous carcinoma feels hard and
woody due to invasion of perianal tissues.
 P/R examination may prove impossible because of
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.
 Above the pectinate line
 Abdomino perineal excision
 Below the pertinate line
 local excision.
 If inguinal LN metastasis present should be
removed by block dissection.
 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
 Rectal examination reveals
the location
type and degree of the stenosis.
 Proctoscopy
 Biopsy
 Dilation
 Superficial external