1. Anal pain and Discharge

2. Anatomy of the anal canal
The anatomical canal is about 3 cm long and it extends from the anal verge to the dentate line
The surgical anal canal is about 4 cm long and it extends from the anal verge to the anorectal junction

3. Anatomy of the anal canal
Pecten (anoderm) is a hairless part of the external anal canal that exposed by traction on the rim of the anus ( lined by keratinized stratified squamous epithelium )
The junction between the Pecten and the large mucosa is known as dentate line .

4. Anatomy of the anal canal
The rectum is lined by columnar epithelium
The transitional zone is lined with cuboidal epithelium that lines the anal canal from the columns of morgagni to the dentate line.
Below the dentate line the anal canal is lined by squamous epithelium .

5. Muscle layers of the anal canal
Internal sphincter (involuntary ) :
is a continuaion of circular smooth of the rectum under control of the autonomic nervous system
External sphincter (voluntary ) :
downward extension of the puborectalis, witch is striated muscle with somatic innervation ( branch of the internal pudendal nerve S2-S4.

6. Differences between the upper and the lower hlaves of the anal canal according to the dentate line
Below the dentate line
Above the dentate line
Ectodermal in origin
Endodermal in origin
Lined by squamous epithelium
Lined by columnar epithelium
Under control of the somatic innervation (sensitive to pain, touch , temperature)
Under control of the autonomic nervous sys. (sensitive to stretch )
Drains its venous blood via inferoir rectal vein into the systemic venous
Drains its venous blood via the sup.
rectal vein to the portal venous
Drains its lymph to the inguinal lymph nodes.
drains its lymph to the internal iliac lymph nodes.

7. Hemorrhoids
Definition : they are engorgement of venous plexi “cushions” that sit in the anorectal junction.
Could be :
External: below the dentate line
Internal: above the dentate line
Commonly situated at :
3 o’clock “left lateral”
7 o’clock “right posterior”
11 o’clock “right anterior”

8. Classification of internal hemorroids
First degree: painless bleeding usually associated with defecation
Second degree: protrude during defecation but spontaneously reduce
Third degree: protrude during defecation and must be manually reduced
Forth degree: permanently prolapsed

9. Possible causes Constipation Straining Anorectal carcinoma Portal HTN
Pregnancy

10. Signs and symptoms Painless bright red rectal bleeding Prolapsing lump
Itching
Mucus discharge
N.B.
sever pain is not typically associated with internal hemorrhoids but is commonly seen with thrombosed external hemorrhoids
but if pain is present with absence of strangulation look out for other conditions “fissure , hematoma, abcess”

11. Clinical assessment History: Age, type of bleeding, bowel habit
Examination:
Digital rectal examination
Investigation:
Protoscopy , rigid sigmoidoscopy, colonscopy,
Barium enema.

12. complications Profuse hemorhage Ulcerations Fibrosis Strangulation
Gangrene
thrombosis

13. Treatment Advice the patient to : receive a high fiber diet
use laxatives
avoid straining
sitz bath
keep a good hygiene

14. Cont. treatment The definite treatment varies according to
the degree of hemorroids:
1st degree : sclrotherapy
infrared photocoagulation
cryothrapy
2nd degree : rubber band ligation
3rd and 4th degree : hemorrhoidectomy

15. Cont. treatment
Thrombosed external hemorrhoids should be excised if seen within 48 hr, beyond this time, conservative therapy with analgesics and sitz baths is appropriate.

16. Cont…

17. Anal Fissure
Definition It is painful liner tears in the lining of the anal canal below the dentate
line i.e. ( tear in squamous epithelium ).
It is the commonest cause of sever anal pain

18. Epidemiology
Acute or chronic tear in the anal canal usually in posterior midline ( M=F in young adult)
Anterior fissure is common in Females.
Lateral or multiple fissures should raise suspicion of trauma, inflammatory bowel disease ( Chron’s disease), lymphoma, neoplasm or infection.

19. Causes Constipation Inflammatory bowel disease
Sexual transmitted disease
Post anal surgery

20. Signs and symptoms burning pain is associated with defecation.
Bleeding : the blood is usually bright red and associated with acute fissures.
Physical exam
Acute fissure showing just tear in the anal mucosa.
Chronic fissure may reveal a sentinel tag or hypertrophied papilla.

21. Treatment Conservative ( acute fissure ) - fiber supplement
- bulk laxatives
- stool softner
- sitz baths
- topical nitroglycerine ointment
- Botox

22. Cont. Treatment
Surgical ( with chronic fissure to reduce the internal sphincter spasm )
- sphincter dilation
- Lateral internal sphincterotomy