Presentation is loading. Please wait.

Presentation is loading. Please wait.

Y. Ziv, 2008 Proctology Hemorrhoids Anal - Fissure Fistula - Ani Constipation ( O bst. D efacation S yndroms ) Incontinence Tumors ( Benign & Malignant.

Similar presentations


Presentation on theme: "Y. Ziv, 2008 Proctology Hemorrhoids Anal - Fissure Fistula - Ani Constipation ( O bst. D efacation S yndroms ) Incontinence Tumors ( Benign & Malignant."— Presentation transcript:

1 Y. Ziv, 2008 Proctology Hemorrhoids Anal - Fissure Fistula - Ani Constipation ( O bst. D efacation S yndroms ) Incontinence Tumors ( Benign & Malignant ) Infections ( Viral, Bacterial, Fungi, Chemical, Allergic, Others ) Yehiel Ziv, MD, Assaf-Harofe Med. Ctr. Chairman, The Isreal Society of Colon & Rectal Surgeons

2 Y. Ziv, 2008 Anal canal Int. anal sphincter Ext. anal sphincter Levator ani muscle anal columns

3 Y. Ziv, 2008 Anal canal Int. anal sphincter Ext. anal sphincter Levator ani muscle rectum deep part superficial part subcutaneus part

4 Y. Ziv, 2008 anal column anal valve tributaries of superior rectal vein external anal sphincter internal anal sphincetr tributaries of inferior rectal vein ANAL SINUS conjoint longitudinal muscle intermuscular groove [white line of Hilton] pecten

5 Y. Ziv, 2008 Levator ani muscle Ano-rectal line anal gland

6 Y. Ziv, 2008

7 levator ani muscle external anal sphincer internal anal sphincter ischioanal fossa fibrous septum of ischioanal fossa conjoint longitudinal muscle

8 Y. Ziv, 2008 Hemorrhoids

9 Y. Ziv, 2008 Hemorrhoids Normal components (sub-mucosal vascular tissue) of human anatomy External (Inf. Hem. Plexus, Somatic Nerve) Internal (Sup. Hem. Plexus, Above DL, Senseless) Mixed 2 – Right Side, Anterior & Posterior 1 – Left Side M = F, Peak = 45-65y

10 Y. Ziv, 2008 Hemorrhoids Pathogenesis : - Increased age - Ch. diarrhea or constipation - Increased Intra - Abdominal Pressure (prolonged sitting, pregnancy etc.) Hypothesis: Hypertrophy or Increased Muscle Tone

11 Y. Ziv, 2008 Hemorrhoids Internal Hem. Classification 1 st deg : project into lumen & bleed. 2 nd deg : protrude – spont. reduction 3 rd deg : protrude – manual reduction 4 th deg : irreducibly prolapsed.

12 Y. Ziv, 2008 Hemorrhoids Diagnosis Medical History Physical Examination Inspection Digital Exam. Rectoscopy

13 Y. Ziv, 2008 Hemorrhoids Symptoms : –Ext, Hem. Pain, bleed, swelling –Int, Hem. Bleed, swelling, soilage, itching, pain, discharge, protrusion.

14 Y. Ziv, 2008 Hemorrhoids Medical Treatment : Sitz baths, Diet, Hygiene, Stool modifiers, Topical creams, Suppositories.

15 Y. Ziv, 2008 Hemorrhoids Minimally Invasive Treatment : Int, Hemorrhoids (Grade 2-3) RBL IRC Sclerotherapy Cryo

16 Y. Ziv, 2008 Hemorrhoids Surgical Treatment : Ext, Hem. Thrombectomy ( Emergency ) Excision ( Failed Med. Treat.) Int, Hem. Excision or Resection with Anopexy or DHL ( Failed Med. or Invasive Treat. 4 th degree, Association with other anal disease )

17 Y. Ziv, 2008 Hemorrhoids Surgical Treatment : Anal Dilatation (rarely used) Excision : - Open (Milligen-Morgan) - Closed (Fergusson) - Semiclosed Resection with Anopexy (Longo Proc.) Trans Anal Ligation of Hem. Arteries

18 Y. Ziv, 2008 Hemorrhoids Surgical Options : Scissors & Scalp Ligasure Harmonic Scalpel Laser Stapler DHL

19 Y. Ziv, 2008 Hemorrhoids Surgical Treatment : Complications : – Incontinence, Stenosis, – Bleeding, Urinary Retention – Infection (absc., fistula) > Sepsis – Persistent Hemorrhoids

20 Y. Ziv, 2008 Hemorrhoids Incarcerated Hemorrhoids Treat Medically !!! (Rest, Magnesium Sulphate 30%, Suppsitories, Stool-softeners) Avoids Complications Rate

21 Y. Ziv, 2008 Hemorrhoids Hemorrhoids in Pregnancy Treat Medically or Minimally Invasive Failure Surgery

22 Y. Ziv, 2008 Anal Fissure Vertical tear in squamous epihelial lining of the anal canal between the anal verge and the dentate line Location : Post – 85%, Ant - 10%, Lat – 5%

23 Y. Ziv, 2008 Anal Fissure Acute – N o secondary changes Chronic – > 30d – Symptoms > 50% – Secondary changes

24 Y. Ziv, 2008 Anal Fissure Secondary changes: –Sentinel tag (sometimes w fistula) –Hypertrophied anal papilla –Indurated edges –Exposed Int. Sphincter fibers

25 Y. Ziv, 2008 Anal Fissure Etioligy : - Trauma - Spec. underlying Disease : Chlamidia, Gonorrhea, Herpes, Syphillis, Aids, TB, Neoplasia, Crohn, Ulcerative Colitis.

26 Y. Ziv, 2008 Anal Fissure Pathogenesis : - Repeated trauma - Raised Mean Rest. Pressure - Spasm, ischemia “Stress fractures of the anal canal“ - Underlying disease

27 Y. Ziv, 2008 Anal Fissure Symptoms : – Pain, bleeding, discharge, swelling, itching. Diagnosis : -Inspection, palpation -Anoscopy/rectoscopy (not recom.)

28 Y. Ziv, 2008 Anal Fissure Treatment Acute AF – Medical : Diet, Bulk laxatives, Sitz baths, Topical creams. Chronic AF – Medical, Surgery

29 Y. Ziv, 2008 Anal Fissure Medical Treat. of Chronic AF - Diet, Bulk lax., Sitz baths, Creams. “Chemical” Sphincterotomy - NTG, ISDN - NO transmitor - Nifedipine - Ca Channel Blocker - Botolinum A -ACE Inhibitor - Alpha-1 adrenoceptor blockade

30 Y. Ziv, 2008 Anal Fissure Surgical Treat. of Ch AF - Open / Closed LIS - Anal Dilatation ( only in special cases ) - Fissurectomy - Advancement Flap (from inside or outside)

31 Y. Ziv, 2008 Anal Fissure Surgical Treat. of Recurrent Ch AF - Open / Closed LIS (other side, after TRUS) - Anal Dilatation ( only in special cases ) - Fissurectomy - Advancement Flap (from inside or outside)

32 Y. Ziv, 2008 Anal Fissure Complications – Incontinence Conservative, Surgery – Stenosis Dilatation, Surgery – Hemorrhage Hemostasis – Infection, Ab, Drainage – Urin. Reten. Cateterization

33 Y. Ziv, 2008 Anal Fistula Pathogenesis : Infected Anal Glands (open to Dentate Line) Ductal Obstruction lead to ; Stasis, Infection, Abscess. 50% develop Fistula

34 Y. Ziv, 2008 Anal Fistula Signs & Symptoms : Pain, Pruritus, Bleeding, Discharge. Pressure (evacution, cough, sitting) Swelling Fever Ano-rectal Pain & High Temp. = Abscess, until proven otherwise !

35 Y. Ziv, 2008 Anal Fistula Diagnosis: History & Physical Examination Digital Examination Ano/Rectoscopy EUA Fistulography TRUS CT-Fistulography MRI (Ext., Coil)

36 Y. Ziv, 2008 Anal Fistula Park’s Classification: –Trans - Sphincteric – Inter - Sphincteric – Supra - Sphincteric – Extra - Sphincteric

37 Y. Ziv, 2008 Anal Fistula Other Classification : – Simple Vs Compound (horseshoe) – Low, Middle, High (Anal Canal) – Small, Large (Int. opening) Special Fistulas Recto - Vaginal Fistula, Associated with Underlying Disease (TB, IBD, Irradiation, Infections)

38 Y. Ziv, 2008 Anal Fistula Asymptomatic Fistulas Require No Therapy !!! Medical Treatment May Cure Simple Mild Symptomatic Fistulas ( sitz-baths, antibiotics )

39 Y. Ziv, 2008 Anal Fistula Surgical Treatment : Fistulotomy or Fistulectomy Fibrin Glue Anal Plage Seton Placement (Loose, Tight) RAF (Mucosal or Full Thickness) Colostomy Anterior resection Patches (Omentum, Muscles)

40 Y. Ziv, 2008 40 ODS Obstructive Defacation Syndroms מצב שבו החולה אינו מסוגל להתרוקן באופן רגיל ונאלץ להשתמש במשלשלים, חוקנים או אמצעים אחרים. –כאבים בזמן יציאה –צורך במאמץ חריג על מנת להתרוקן –ישיבה ממושכת בשירותים –מרווחים ארוכים בין היציאות 5-10 ימים –אי נוחות באזור חייץ הנקבים בזמן עמידה –תחושה מתמדת של חוסר התרוקנות Tenesmus = –התרוקנות לא רציפה Incomplete Evac = –הפרעות בשליטה = Incontinence

41 Y. Ziv, 2008 41 אבחנה של ODS הופעה קבועה ביותר מרבע היציאות ב-12 השבועות האחרונים של: –מאמץ מוגבר ביותר ביציאה –צואה קשה וגושית –הרגשה של חוסר התרוקנות –הרגשה של הפרעה או חסימה ביציאה –שימוש ביד לצורך יציאה- לחץ וגינאלי, רקטלי, לחץ על חיץ הנקבים –פחות משלוש יציאות לשבוע

42 Y. Ziv, 2008 42 הברור הקליני לפני הניתוח על החולה לעבור סדרה של בדיקות אשר יגדירו האם הוא מתאים ליפול שמרני או ניתוח דפקוגרפיה מנומטריה בדיקת EMG אלקטרומיוגרפיה בדיקת זמן מעבר TTI בדיקת TRUS

43 Y. Ziv, 2008 43 גורמים ל ODS Intussusceptions (rectal invagination) Rectocele Genital Prolapse Enterocele

44 Y. Ziv, 2008 Thank You !


Download ppt "Y. Ziv, 2008 Proctology Hemorrhoids Anal - Fissure Fistula - Ani Constipation ( O bst. D efacation S yndroms ) Incontinence Tumors ( Benign & Malignant."

Similar presentations


Ads by Google