Anal fissure (fissure in ano) Is a longitudinal split (ulcer) in the anoderm of the distal anal canal Location :90% midline posterior AE/ post. Wall of rectum curved forward to join anal canal then turns sharply backward, during defecation ..pressure of hard fecal mass …post. anal tissue (unsupported by muscle )----tear. Women ….anterior more (damaged pelvic floor) recent …..ischemia Other causes : posthaemorrhoidectomy..Infl. bowel dis., sexually trans. dis.

Pathology - indurated margins ,canoe shape Acute anal fissure: deep tear ..skin.. from dentate line to anal verge little inflam. Indurations edge spasm of internal sphincter Chronic anal fissure: - indurated margins ,canoe shape - skin tag …inf. edge (sentinel pile) - hypertrophied anal papillae - long standing ….internal sphincter …contracted by infiltration of fibrous tissue

Clinical features Symptoms: Age: adult life …not rare in children Sex: male =female Pain: sharp agonizing Constipation Bleeding slight bright streaks on the stool Mucous Discharge and itching On exam.: Sentinel tag Tightly closed puckered anus Long. Ulcer male… post. (1% ant.) , female …post .(10% ant.) Palpation only in chronic fissure with good local anesthesia ..button hole

Differential diagnosis 1- ca. of anal canal 2- multiple fissures or atypical sites ( infl.bowel.dis., sexually trans. Dis. Scratching, homosexual practice) So any atypical ulcer or site need biopsy 3- tuberculous ulcer 4- proctalgia fugax: attacks of pain in rectum( segmental cramps of puborectalis muscle

Treatment Aim to obtain complete relaxation of inter. Sphincter Conservative treat.: Laxatives …stool soft and bulky.(celevac tab. Or senna tab.) Anal dilatation Nitric oxide :glyceryl trinitrate 0.2% Diltiazim 2% twice daily. Botulin toxin (paralysis of anal sphincter)

Tratment Operative measures: Gentle dilatation of the sphincter( not used now) Lateral anal sphincterotomy GA,LA lower 1/3 of inter.sphincter ….3 weeks Dorsal fissurectomy and sphincterotomy (healing time more 3 W, mucus discharge, incontinence) Anal advancement flap: recently used

HaemorrhoidS(pile) Dilated veins occurring in relation to the anus such H. may be internal ,external or interoexternal. Internal H.: Is displaced anal cushions due to a dilatation and enlagement of internal venous plexus . A etiology: 1- hereditary: cong. weakness,abnormal large arterial supply

A etiology: 1- hereditary: cong A etiology: 1- hereditary: cong. weakness,abnormal large arterial supply 2- morphological: weight of column of blood 3- anatomical: loose submucous C.T., constricted by muscle 4- exacerbating factors: constipation, diarrhea

Pile may be symptomatic some other cond. 1- Ca. of rectum. 2- pregnancy: compression on sup. rectal vein relaxing effect of progesterone increase pelvic circulating volume 3- straining at micturation

Pathology Arranged in three group 3,7 and 11 o’clock each pile divided to three parts: 1- pedicle at anorectal ring 2- internal H below anorectal ring and dentate line 3- external H bet. Dentate and anal verge

Clinical features symptoms: 1- bleeding: painless …1st degree 2- prolapse : on defecation but return….2nd degree or replaced manually ….3rd degree Permanently prolapsed ….4th degree 3- discharge and pruritis 4- pain only in complicated case 5- anaemia: profuse bleeding

On exam. Inspection: no finding in int .H….early Diagnosis by proctoscopy Sigmoidoscopy should be done

Complications Profuse haemorrhage Strangulation Thrombosis….ulceration ….supuration ..pylephlebitis(portal pyaemia) …fibrosis 4. Gangrene

Treatment Non operative treatment: Symptomatic treatment: Bulk laxative Increase water and fiber diet Avoid prolong sitting on toilet Various compound preperations cream or ointment

Active treatment: 1- injection treatment: 1st degree, early 2nd 5 % phenol in almond oil submucously 2- banding (Barron) 2nd degree 3- cryosurgery: application of liquid nitrogen 4- photocoagulation:

Operative treatment Haemorrhoidectomy: Indications: 3rd and 4th degree, 2nd degree not cured by non operative treatment ,fibrosed H. , interoexternal H., profuse bleeding Surgical excision of piles - open - close - stapled haemorrhoidectomy (endostapling technique Postoperative complication: Early :pain..urine retension…reactionary haemorrhage Late :secondary haemorrhage..anal stricture..anal ... incontinence ,submucous abscess .fissure

Management of complications 1 –profuse hemorrhage: . Admission to the hospital . Wide bore canula ,give fluid then blood . Morphine . operation 2- strangulation: . Admission . Analgesia . AB Warm bath, warm or cold pack with saline surgery

External haemorrhoids 1- Thrombosed external H.( perianal haematoma) small clot ……perianal C.T back pressure on anal venule …straining, coughing, lifting a heavy weight sudden sever painful swelling on exam. Olive like bluish Tense tender swelling, haematoma sequel:resolution,fibrosis(5 days self curing lesion inflammation, burst (bleeding) 2- external associated with Int.H 3- dilatation of the veins of the anal verge