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Common Office Anorectal Problems Sandra J. Beck, M.D., FACS, FASCRS Associate Professor of Colon and Rectal Surgery University of Kentucky Medical Center.

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Presentation on theme: "Common Office Anorectal Problems Sandra J. Beck, M.D., FACS, FASCRS Associate Professor of Colon and Rectal Surgery University of Kentucky Medical Center."— Presentation transcript:

1 Common Office Anorectal Problems Sandra J. Beck, M.D., FACS, FASCRS Associate Professor of Colon and Rectal Surgery University of Kentucky Medical Center

2 Disclosures None

3 Benign Anal Rectal Disease Anatomy of the anal canal and perianal spaces Benign Anal Rectal Disease –Abscess and Fistula –Fissure –Hemorrhoids

4 Overview of Anatomy Anatomy –Pelvic and Perirectal Spaces –Anatomy of Anal Canal

5 Retrorectal Space Waldeyer’s Fascia Supralevator Space Levator Ani Muscle Deep Postanal Space Superficial Postanal Space

6 Peritoneum Levator Ani m. Puborectalis m. Deep External Sphincter m. Internal Sphincter m. Transverse Septum Supralevator Space Ischioanal Space Intersphincteric Space Perianal Space ANAL CANAL

7 Anal Transitional Zone Column of Morgagni Dentate Line Anal Crypt Anal Gland Anoderm

8 Patient complaints Anal Pain Bleeding Drainage Time course Fissure Knifelike pain with BM Passing Glass Brick, Throbing Pain with BM:minutes to hours Blood on toilet paper No drainage Small tag or “hemorrhoid” Hemorrhoid Acute or Chronic Bleeding itching burning Sudden swelling, +/- pain Prolapse Difficulty with hygiene Pain rarely knifelike Abscess Generally Acute Minimal bleeding Pain Swelling over large area not associated with BM +/-Purulent Drainage Rapid increase in size

9 Diagnosis and Treatment of Anorectal Abscess and Fistula-in- Ano

10 Anorectal Abscess Etiology Cryptoglandular abscess –Most common –Infection in the glands at the dentate line Other causes –Crohn’s and Ulcerative Colitis –Tuberculosis and Actinomycoses –Malignancy –Foreign Bodies, Prostate Surgery or Radiation

11 Fistula Description Clock description –Does the anus tell time? –Relies on description of patient’s position: supine, lateral, prone and relative landmarks Anatomic description: more consistent –Pubic bone defines anterior –Coccyx define posterior –Right and left –* If terms be incorrect, then statements do not accord with facts; and when statements and facts do not accord, then business is not properly executed." Confucius 1

12 Tailbone Right anterior Right posterior Left anterior Left posterior Right Left Pubic bone

13 There is an area of induration and erythema in the right posterior quadrant that is likely an abscess that has spontaneously drained

14 Abscess Classification Four Types Based on Space Involved –Perianal % –Intersphincteric % –Ischioanal % –Supralevator 2% or less Most Common Rare

15 Supralevator Abscess Perianal Abscess Ischioanal Abscess Intersphincteric Abscess

16 Supralevator Space Intersphincteric Space Ischioanal Space HORSESHOE ABSCESS

17 Anorectal Abscess Treatment of Perianal and Ischiorectal Abscesses Diagnosis - usually straightforward –Erythema and Pain over affected area –Fluctuance Treatment –Incision and Drainage –+/- Excision of small amount of overlying skin –Initial packing for hemostasis –Drainage catheter (Pezzer) or pack wound –Attention to good hygiene and control blood sugar –Antibiotics if immunocompromised, obese or diabetic

18 Small Radial incision Short distance from anus – feel for soft spot Place drain and trim – avoids packing Follow up in 7-10 days to remove drain

19 Catheter Types Pezzer catheter Solid mushroom top so stays in Less tissue ingrowth Malecot Allows tissue ingrowth More painful to remove

20 Peri anal abscess - ? Antibiotics Not usually indicated if there is adequate drainage Indicated for patients with: –Obesity –Diabetes –Imunocompromised –Extensive large abscess or recurrent abscess

21 Fistula-in-Ano Definition –abnormal connection between two epithelial surfaces. Classification: –Parks: Defines fistula by course of tract –Goodsall’s rule Diagnosis Treatment –Goals –Options

22 How does patient present? May have had a history of abscess History of Crohn’s disease May present at the same time as abscess Complain of intermittent increase in pain/swelling followed by spontaneous drainage Chronic localized area of irritation or ulcer “pimple near my anus keeps coming back”

23 Fistula-in-Ano Goodsall’s Rule Posterior Anterior

24 Fistula in ano

25 Fistula in ano: Surgical disease Refer to Colon and Rectal Surgeon or General Surgeon Reassure patient – rarely cancer, most do not need a colostomy If suspect Crohns –Gain control of perianal sepsis –Then complete full workup and staging Goals of therapy –Get rid of the fistula/connection –Preserve continence

26 Surgical Options Primary fistulotomy –Mainly for low, superficial fistula –Risk of fecal incontinence Fibrin Glue/Fistula Plug –Utilizes substrate as scaffold to fill tract –Does not involve cutting muscle Cutting or draining setons –For deeper tracts that involve significant muscle –Risk of fecal incontinence Rectal advancement flap Lateral internal fistula transection –Newer procedure. No foreign substrate –Cuts fistula tract, not muscle

27 Fistula in ano

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29 Fissure in Ano Definition – a painful linear ulcer situated in the anal canal and extending from just below the dentate line to the margin of the anus –Overlie the lower half of the internal sphincter –~73.5% are posterior –~16.4% are anterior –~2.6% both anterior and posterior

30 Fissure in Ano Pathogenesis Acute fissure results from trauma to the anal canal most commonly from a large fecal bolus Secondary changes of chronic fissure include –Sentinel pile or skin tag at the distal end –Hypertrophied anal papilla-swelling, edema and fibrosis near the dentate line –Fibrosis of the internal sphincter at the base

31 Fissure with Sentinel Tag

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33 Fissure in Ano Pathogenesis Perpetuating factors in chronic fissure –Persistent hard bowel movement –Abnormal high resting pressure in the internal anal sphincter –Increased pressure in the sphincter causes a decrease in blood flow, preventing healing of the fissure

34 Fissure in Ano Symptoms Pain is the main symptom –Sharp, cutting or tearing during defecation –Duration is few minutes to hours Bleeding – bright red and scant Skin Tag Mucous discharge resulting in itching

35 Fissure in Ano Diagnosis Diagnosis often made on history alone Inspection – gently spread the buttocks and the fissure becomes apparent Triad of chronic anal fissure –Sentinel pile –Hypertrophied anal papilla –Anal ulcer

36 Fissure in Ano Differential Diagnosis Intersphincteric abscess Pruritus Ani Fissure from inflammatory bowel disease Carcinoma of the anus Infectious Perianal conditions Leukemic infiltration

37 Fissure in Ano Crohn’s Anal Fissures

38 Acute Fissure in Ano Treatment Increase dietary fiber Local anesthetic to prevent spasm Nitroglycerin or Nifedepine Ointment –Not commercially available –Must be mixed by pharmacist Warm tub soaks 4-6 weeks of treatment

39 Chronic Fissure in Ano Surgical Treatment Indicated on Chronic non-healing anal fissure and fissure that is refractory to medical therapy –Lateral Internal Sphincterotomy Forces the muscle to relax –V-Y Anoplasty flap Allow coverage of fissure with healthy tissue

40 Hemorrhoids What are they? Where are they? Why do they become symptomatic? Classification? How do you treat them? Can they be avoided?

41 Hemorrhoids What are they? Specialized highly vascular cushions consisting of discrete masses of thick sub mucosa that contain blood vessels, smooth muscle and connective tissue Aid in anal continence

42 Hemorrhoids Where are they? Internal Hemorrhoids –3 major bundles – left lateral, right anterior and right posterior –Above the dentate line –Blood drains into the superior rectal vessels then into the portal circulation External Hemorrhoids –Below the dentate line –Blood drains through the inferior rectal veins to the pudendal veins on into the iliac veins

43 Hemorrhoids Symptoms? Chronic constipation Diarrhea Trauma to the hemorrhoids during defecation cause the most common symptoms –Pain – generally not “knife-like” –Itching –Burning –Bleeding

44 Hemorrhoids Classification- Internal Hemorrhoids 1 st degree – bulge into the lumen 2 nd degree – prolapse with bowel movement but reduce spontaneously 3 rd degree – prolapse spontaneously and require manual reduction 4 th degree – permanently prolapsed hemorrhoids that cannot be reduced

45 4 th Degree Hemorrhoids

46 Hemorrhoids Treatment Principles Thorough physical exam to determine severity and rule out other pathology –Refer for surgical evaluation if white or discolored, firm or fixed Determine if the problem is internal, external or both Assess the symptom complex

47 Treatment Topical agents: Proctofoam, Anusol HC Analpram, Proctosol cream… Conservative therapy –Bulk agents – i.e. high fiber Fruits, vegetables, oat bran, psyllium –Increase water intake –Avoid caffeinated beverages –Avoid prolonged sitting on the commode –Warm tub soaks

48 Treatment Office and Minor Procedures Rubber band ligation –Performed in the office –Indicated for Grade 1 and 2 internal hemorrhoids –Band is applied through an anoscope at the top of an internal hemorrhoid –Severe perianal sepsis – Classic Triad Delayed anal pain Urinary retention Fever

49 Treatment Office and Minor Procedures Infrared Photocoagulation –Indicated in 1 st degree hemorrhoids –Causes photocoagulation of small vessels –Performed in office or “Hemorrhoid Relief Center” –Minimal pain

50 Closed Hemorrhoidectomy Indication Hemorrhoids are severely prolapsed and require manual replacement Patients fail to improve after multiple applications of non-operative treatment Hemorrhoids are complicated by associated pathology such as ulceration, fissure, fistula, large hypertrophied anal papilla or extensive skin tags

51 Closed Hemorrhoidectomy General Principle Most can be performed with local and IV Sedation Prone/Kraske position is the best Infuse the area with local anesthetic with epinephrine for hemostasis Fleets enema 1-2 hours prior No antibiotic prophylaxis is necessary

52 Closed Hemorrhoidectomy

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54 Closed Hemorrhoidectomy Post op Result

55 PPH Stapling Procedure for Hemorrhoids Not for every hemorrhoid Ideal for Grade 2 and 3 with minimal external component Prevents prolapse and thus less trauma to hemorrhoid with bowel movement

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57 PPH Stapling Procedure for Hemorrhoids

58 Benefits –Less pain as compared to traditional closed hemorrhoidectomy –Less blood loss during the procedure –Less chance of anal stenosis

59 PPH Stapling Procedure for Hemorrhoids Risks –If staple placed too low – severe chronic pain and incontinence –If staple line placed too high – failure to relieve symptoms of hemorrhoids –Hemorrhoids are not removed so they may continue to bleed –Perianal sepsis –Rectovaginal fistula

60 Perianal Condyloma Can sometimes be difficult to distinguish from hemorrhoids Cauliflower type appearance History of HIV, History of abnormal pap smear Homosexual males usually but can be seen in the heterosexual population Caused by HPV virus Increased risk of anal cancer in the immunocompromised patient

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62 Treatment - Topicals Aldara (Imiquinod) >50% initial response Topical 5-FU – 90% initial response Condylox (podofilox) Each have high local toxicity Practice Parameters for Anal SquamousNeoplasms

63 Treatment Photodynamic therapy Wide Local Excision Targeted destruction with cautery and/or Infrared coagulation Observation of AIN I/II with removal of visualized lesions Excision of AIN III

64 Anal Squamous AIN High recurrence rate with all techniques Close follow up to detect progression to invasive carcinoma Anal pap smear vs high resolution anoscopy Optomize underlying conditions

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