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Back to medical school -anorectal disorders Ian Botterill, Dept Colorectal Surgery Leeds General Infirmary.

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Presentation on theme: "Back to medical school -anorectal disorders Ian Botterill, Dept Colorectal Surgery Leeds General Infirmary."— Presentation transcript:

1 Back to medical school -anorectal disorders Ian Botterill, Dept Colorectal Surgery Leeds General Infirmary

2 Wide variety of pathologies congenital / acquired benign / malignant traumatic infective / inflammatory gender / age related

3 Common symptoms of ano-rectal disorders bleeding anal pain itch faecal leakage / hygiene problems swelling discharge

4 Examination abdomen groins (lymph nodes) dermatoses

5 Ano-rectal examination chaperoned relaxed patient left lateral good light knee elbow position use pt’s hand to elevate right buttock +/- anoscopy in 1y care

6 Ano-rectal examination External appearance -skin condition -swellings -soiling / discharge -perineal descent -scars Digital examination -sphincter tone -squeeze pressure -cervix / prostate -coccyx -retrorectal space -rectocoele

7 Anatomy

8 Haemorrhoids Symptoms: - anal canal bleeding, pruritus, swelling, pain

9 Haemorrhoids Classification - 1y:bleed, do not prolapse - 2y:prolapse & reduce spontaeously - 3y:prolapse & require manual reduction - 4y:prolase, not reducible

10 Cause of haemorrhoidal problems altered bowel habit raised intra-abdominal pressure straining

11 Treatment of haemorrhoids Diet -five helpings fibre / d Out-patient -injection sclerotherapy -banding -photocoagulation

12 Surgical treatment For 3 rd / 4 th degree haemorrhoids Open haemorrhoidectomy Closed haemorrhoidectomy Ligasure haemorrhoidectomy Stapled haemorrhoidopexy (PPH)

13 Results of haemorrhoidectomy >90% daycase least initial pain -stapled haemorrhoidopexy -Ligasure haemorrhoiodectomy quickest return to work: -stapled haemorrhoidopexy -Ligasure haemorrhoidectomy most costly: PPH / ligasure lowest recurrence (prolapse) ; conventional

14 Complications of haemorrhoidectomy Local - stenosis - faecal leakage - recurence - bleeding - retention of urine severe perineal sepsis (esp IDDM & immunosuppressed)

15 Painful prolapsed haemorrhoids natural history (worst pain days ~ 3-7, then settles) most resolve with conservative Rx - lactulose / topical anaesthetic creams / ice / paracetamol & NSAIDs / relief of anal spasm (GTN or diltiazem) - failure to resolve > haemorrhoidectomy - refer gangrenous or those that fail to settle interval haemorrhoidectomy if still problematic

16 Anal skin tags Sx: anal swelling / hygiene problems Diagnosis: perineal examination alone Differential: Crohn’s disease / anal warts Rx: reassurance / excision

17 Rectal mucosal prolapse & full thickness rectal prolapse

18 Rectal mucosal prolapse result of straining associated with pruritus ani / mucous discharge anoscopy Rx - dietary correction - advised to avoid straining at stool - injection sclerotherapy

19 Ano-rectal sepsis Sx: perineal pain (throbbing), possible prior history of similar Exam:tender fluctuant mass +/- discharge, may be toxic Beware:diabetics (risk of rapidly progressive infection & Fournier’s gangrene) skin necrosis (possible Fournier’s gangrene) anal spasm & throbbing pain (inter-sphincteric abscess) Treatment: I&D

20 Fistula in ano ~ 30-40% of all perineal sepsis once drained goes on to develop a fistula ~ 80-90% of perineal sepsis that yielded enteric organisms will develop a fistula

21 Fistula in ano 95% cryptoglandular - ie origin in ano-rectal crypts at dentate line 5% rarities - Crohn’s - TB - hidradenitis suppurativa - traumatic - malignancy - complicated diverticular disease - radiation - anastomotic leakage

22 Classification Inter-sphincteric70% Trans-sphincteric25% Supra-sphincteric~5% Extra-sphincteric<1% Simple v. complex ‘Complex’: -branching tracts / 2y tracts -associated abscess -associated pathology

23 Goodsall’s rule External opening posterior to 3-9 oclock position open in posterior midline of the anal canal External opening anterior to 3-9 oclock position open radially in the anal canal ~80-90% accurate

24 Management of fistula in ano Strike a balance between -cure of fistula -prevention of further anorectal abscess -preservation of continence

25 Management of fistula in ano Divide tissues overlying track ( to allow healing by 2y intent) - lay open - cutting seton Occlude internal opening & provide external drainage - anal fistula plug - rectal or anal advancement flap Prevention of further ano-rectal sepsis - draining seton

26 Anal fissure ‘focal linear deficiency of anal mucosa’ posterior > anterior acute v. chronic -chronic: IAS exposed, > 6/52, keratinisation simple v. complex

27 Anal fissure

28 Anal fissure management stool softeners dietary advice topical LA chemical sphincterotomy -topical -injected surgical sphincterotomy

29 Anal fissure surgery through the ages anal stretch lateral sphincterotomy chemical sphincterotomy - topical - injectable

30 Anal fissure treatment GTN40-50% successful s/e: severe headaches Diltiazem60-80% successful s/e: nil generally Botox60-90% successful s/e transient minor leakage Sphincterotomy98% successful s/e 2% passive leakage

31 Proctitis Biopsy mandatory (with exception of prior prosate / cervical brachytherapy) UC / Crohn’s / indeterminate / infective Stool culture Biopsy prior to starting suppositories Suppositories often preferable to oral therapy

32 Pilonidal sinus / & abscess Abscess often deep-seated – do not respond to antibiotics

33 Pilonidal sinus disease

34 Z plasty Uli Szymanovski Developed ‘Z’ plasty wound closure

35 Rhomboid flap Healing by 1y intention ~90% of time as with Z plasty

36 Healing by 2y intent

37 Healing using Vac Therapy

38 Perianal haematoma Thromobosis of superficial haemorrhoidal veins Discrete circular lump at / beyond anal verge Incise & drain

39 Pruritus ani Night > day Rule out coexistent dermatoses / renal failure / liver disease If fungal disease suspected > skin scrapings Ano-rectal examination & proctoscopy. Treat ano-rectal pathology (haemorrhoids / faecal incontinence / anal tags etc).

40 Pruritus treatment Avoid synthetic / tight underwear Avoid perfumed soaps etc Avoid scratching Use hairdryer to dry skin Avoid steroid creams Treat anal pathology / diarrhoea Dermatology involvement Methylene blue injections > ~80% successful - s/e occasional cellulitis / ulcer / incontinence

41 Faecal incontinence - understand continence first! Brain / higher centres Spinal cord Reflex arcs Pudendal nerves Ano-rectal sensation ‘sampling’ Stool consistency Rectal compliance Anal sphincter complex

42 Faecal incontinence Causation Obstetric injury (8-30% sphincter injury rate at childbirth) Post-surgical Faecal impaction Neuropathy / MS / Parkinson’s Poor mobility / impaired cognition Diarrhoea IBS / rectal non-compliance

43 Assessment of faecal incontinence History Examination Endoanal USS (sphincter injury) Anorectal manometry (rest & squeeze strength) Pudendal nerve terminal latency (sensation)

44 Assessment of incontinence Cleveland clinic score - severity of soiling - frequency of soiling - use of pads - lifestyle disruption History of back injury / neurolgical disorder Urinary incontinence Saddle anaesthesia

45 Treatment incontinence dietary measures treat diarrhoea / impaction / IBS non-operative - collagen injections - anal plug sacral nerve stimulation sphincter repair artificial sphincters graciloplasty

46 Anal stenosis Post-surgical Cancer Crohn’s Previous chronic anal fissure Radiation Systemic sclerosis Need EUA to assess all these

47 Anal cancer Sx:itch, bleeding, pain (if below dentate line), swelling, ulcer, groin node Exam:hard, irregular, friable area. Groin nodes possible. ? Coexists with anal warts Differential: haemorrhoids, anal fissure, anal warts, STD Diagnosis:EUA & biopsy

48 Anal cancer -treatment Chemo-radiotherapy Ongoing perineal surveillance Average local control ~ 70% Average cure ~ 70% Salvage surgery for recurrence - APER with rectus flap to perineum Rarely is local excision alone sufficient

49 Hidradenitis suppurativa Superficial fistulating condition ass’d with chronic skin sepsis Axillae > groins > perineum Clinical diagnosis (+/- biopsy) – typically have disease elsewhere Rx: drain sepsis / rotating antibiotics / infliximab / stop smokng

50 Anal papillae Sx: nil (asymptomatic finding typically) Diagnosis: at anoscopy Biopsy: rarely required Treatment: leave alone

51 AIDS & the perineum Wide variety of pathology - fissures / abscesses / fistulae / infections / anal cancer / cutaneous lymphoma - florid warts - pruritus - incontience General principle - suspect immunocompromise - culture / biopsy - avoid agresssive surgery - treat in conjunction with Infectious Diseases / Sexual Health

52 AIDS HSV

53 Other perineal problems -pressure sores Post-sacral Over ischial tuberosity Normally have clear cut antecedant history

54 summary diverse pathology high degree of overlap between 1y and 2y care refer bleeding refer ‘odd-looking’ lesions


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