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ANORECTAL DISEASES Bernard M. Jaffe, MD Professor of Surgery, Emeritus

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Presentation on theme: "ANORECTAL DISEASES Bernard M. Jaffe, MD Professor of Surgery, Emeritus"— Presentation transcript:

1 ANORECTAL DISEASES Bernard M. Jaffe, MD Professor of Surgery, Emeritus
Tulane University School of Medicine

2 ANAL CANAL Borders- Coccyx Ischiorectal Fascia Bilaterally
Female- Perineal Body; Male- Urethra Disorders Common and Generally Benign BUT Painful and Disabling Divided Into Upper and Lower Segments

3 UPPER VS. LOWER UPPER LOWER Below Dentate Line Smooth Mucosa Absent
Above Dentate Line (Marked by Anal Valves) Pleated, Folded Mucosa 12-14 Columns of Morgagni Anal Crypts Between Columns Cuboidal Epithelium Below Dentate Line Smooth Mucosa Absent Squamous Epithelium

4 ANAL SKIN Continuous with Anal Canal Contains Apocrine Glands
Site of Hydradenitis Suppurativa Pain Receptors (Not Stretch) Lesions Drain to Inguinal Nodes

5 VASCULAR Arterial Supply Bilateral, Duplicated
Middle and Inferior Hemorrhoidal Arteries Off Internal Iliac Venous Drainage Internal Iliac Veins to Inferior Vena Cava

6 ANAL MUSCULATURE One Tubular Structure Inside Another
Inner- Continuation of Rectal Circular Layer Extends 1.5cm Beyond Dentate Line Involuntary Forms Internal Sphincter Outer- Continuous Sheet of Striated Muscle of Pelvic Floor External Sphincter Voluntary Control

7 HEMORRHOIDS Abnormal Anal Cushions
Cushions Contain Blood Vessels, Smooth Muscle, Elastic and Connective Tissue Left Lateral, Right Anterior, Right Posterior Positions Unknown Causes, Includes Straining Common During Pregnancy

8 EXTERNAL HEMORRHOIDS Covered by Anoderm Distal to Dentate Line
Swell, Causing Discomfort, Difficult Hygiene Sever Pain Only with Thrombosis

9 INTERNAL HEMORROIDS Cause Painless Bright Red Bleeding
Prolapse with Defecation Mucus Secretion Itching Pain is Rare (No Mucosal Pain Receptors)

10 HEMORRHOID GRADES 1◦ Bleeding Diet
2◦ Prolapse, Bleeding Rubber Band Ligation 3◦ Prolapse with Hemorrhoidectomy or Digital Reduction, or Rubber Band Bleeding Ligation 4.◦ Strangulation Urgent Hemorrhoidectomy

11 OFFICE TREATMENT Dietary Management (for All Grades) Fiber Supplements
Local Hygiene Avoidance of Straining Medication to Soften Stool More Extensive- Rubber Band Ligation

12 HEMORRHOIDECTOMY Indications Failure of Conservative Measures
Prolapse Requiring Manual Reduction Strangulation Ulceration Commonest Complications Bleeding Urinary Retention

13 ANAL FISSURES Almost Always Directly Posterior
If Not- STD’s, Crohn’s, Hydradenitis Associated Findings- Sentinal (External) Pile Enlarged Anal Papilla Causes Pain, Mild Bleeding Responds to Sitz Baths, Bulking Agents

14 ABCESSES Originate in Intersphincteric Plane Usually From Anal Gland
If Progress Downward to Skin Causes Perineal Abcess If Progresses to Other Sites More Complicated Harder to Treat

15 OTHER SITES OF ABCESS Intermuscular- Vertical Tracking
Supralevator- Vertical Tracking Tough to Diagnose Ischiorectal- Horizontal Tracking Horseshoe- Circumferential Tracking

16 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

17 OPERATIVE DRAINAGE OR Required for Complex (Horeshoe Abcess)
High (Supralevator) Abcess Immunocompromised Patients Patients With Systemic Symptoms

18 FISTULA-IN-ANO Complicates Anorectal Sepsis in 25%
Originates in Dentate Line in Anal Canal Presents With Purulent Peri-Anal Drainage Punctate Indurated Papule With Opening Inner Opening Identified by Probing at Dentate Line from Drainage Site May Have Multiple External Drainage Openings

19 TYPES OF FISTULAS Type 1- Intersphincteric Treated by Fistulotomy
Type 2- Transsphincteric Type 3- Supersphincteric Type 4- Extrasphincteric Latter 3 Treated With Seton

20 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 Opening

21 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

22 PILONIDAL SINUS Midline Sacrocoxxygeal Skin Acute Abcess
Chronic Sinuses Rarely Confused With Fistula-in-Ano Related to Hair, Penetration of Granulation Tissue Into Sinuses Disease of Young People Treated by Excision

Peri-Anal Wart Caused by Human Papilloma Virus Associated With AIDS, Anal Intercourse Difficult to Eradicate- Cautery Podophyllin Significant Risk of Epidermoid Carcinoma

Chronic Inflammatory Process Occurs in Peri-Anal Area and Other Hair- Bearing Areas Most Likely Theory- Debris Occludes Apocrine Gland →Purulence → Rupture→ Subqu Infection Organisms- Strep milleri, Staph aureus, epidermitis, and hominis

25 TREATMENT Antibiotics Drainage, Debridement
Fistulotomy (Distal to Dentate Line) Wide Local Excision With Skin Graft Difficult to Eradicate 30% Recurrence Rate Association With Squamous Carcinoma

26 CROHN’S DISEASE 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

Sitz Baths, Stool Softeners, Analgesics Steroids, 6 M-P, Azothiaprine, Cyclosporine Avoid Fistulotomy- If Needed, Use Seton Difficult to Manage- Non-Resposive Often Extensive

28 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

29 TREATMENT Superficial Lesions <2cm- Local Excision
Remainder- Nigro Protocol (Radiation, 5-FU, Mitomycin) Almost All Respond and

30 TREATMENT Superficial Lesions <2cm- Local Excision
Remainder- Nigro Protocol (Radiation, 5- FU, Mitomycin) Almost All Respond and Disappear APR for Failure of Nigro Protocol Contraindication to RT, Chemo Deep Invasion Aggressive Lesion

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