2. Common Anorectal Diseases
Lecturer:
Professor Saleh M. AlSalamah FRCS
Professor of Surgery & Consultant General and Laparoscopic Surgeon
College of Medicine, King Saud University, Riyadh, KSA.

3. References Clinical Surgery by Michael M. Henry
Bailey and Love’s Short Practice of Surgery
Essential of General Surgery by Peter F. Lawrence

4. Objectives At the end of this presentation students will be able to:
Understand the surgical anatomy of the anal canal.
Classification, pathogenesis and management of hemorrhoids.
Pathogenesis, presentation and management of anal fissure.
Presentation. Classification and management of perianal abscess.
Classification and management of anal fistula.
Pathogenesis, presentation and management of anal carcinoma.

5. Anorectal Diseases Overview Surgical Anatomy Examination of the Anus
Common Anal Conditions

6. Overview
Anal and perianal disorders makeup about 20% of all outpatient Surgical referrals.
These conditions are extremely distressing and embarrassing patient often put up with symptoms for long time, before seeking medical care.

7. Common symptoms Anal bleeding Anal pain and discomfort
Perianal itching and irritation
Something coming down
perianal discharge

8. Surgical Anatomy
The anal canal 1.5” (4 cm) long and is directed downward and backward from the rectum to end at the anal orifice.
The mid of anal canal represents the junction between endoderm and ectoderm

11. Surgical Anatomy
The lower ½ is lined by squamous epithelium and the upper ½ by columnar epithelium so carcinoma of the upper ½ is adenocarcinoma. Where as that arising from the lower part is squamous tumour.

13. Surgical Anatomy
The blood supply of upper ½ of the anal canal is from the superior rectal vessels. Where as that of the lower ½ is supply of the surrounding anal skin the inferior rectal vessels which derives from the internal pudendal ultimately from the internal iliac vessels.

15. Surgical Anatomy
The lymphatic above the mucocutaneous junction drain along the superior rectal vessels to the lumbar lymph nodes, where as below this line drainage is to the inguinal lymph nodes.

16. Surgical Anatomy
The nerve supply to the upper ½ via autonomic plexus and the lower ½ is supplied by the somatic inferior rectal nerves terminal branch of the pudendal nerve. So the lower ½ is sensitive to the prick needle.

17. Anal Sphincter
The internal anal sphincter of in voluntary muscle, which is the continuation of the circular muscles of the rectum.
The external sphincter of the voluntary muscles, which surrounds the internal sphincter and comprises 3 parts (formerly)
subcutaneous the lower most portion of the external sphincter
superficial part
deep part

19. Common Anal Conditions
Haemorrhoids
Pruritus ani
Perianal abscess
Anal fissure
Anal fistula
Rectal prolapse
Anal in continence
Non malignant strictures
Anal neoplasms

22. Examination of Anus
This requires careful attention to circumstances (couch, light, gloves). The Sims (left lateral position) is satisfactory. The examination proceed by;
inspection
digital examination with index finger
proctoscopy
sigmoidoscopy

24. Hemorrhoids
Piles may be internal or external according to whether they are internal or external to anal orifice.
The internal Haemorrhoids:
They are dilation of the superior haemorrhoidal veins above the denate line each pile consists of mass of dilated vein, artery, some connective tissue and mucosal investment.

27. Hemorrhoids
The location of piles, right anterior, right posterior and left lateral situated respectively 11, 7, 3 o’clock with patient in the lithotomy position, these are give daughter piles.

29. Etiology Primary Causes:
Hereditary factors e.g, structural weakness of the vein.
Anatomical factors.
Partial congestion.
Chronic constipation.
Sphincteric relaxation.

30. Etiology Secondary Causes: venous obstruction straining on micturation
pregnancy
venous obstruction
straining on micturation
venous congestion
carcinoma of the rectum

31. Clinical features Bleeding at defecation Prolapse
Discharge with pruritus ani
Pain
Thrombosed piles

32. Assessment and Diagnosis
Careful history
Abdominal Examination
Anorectal Examination
Investigation e.g., proctoscopy

33. Complications
Profuse haemorrhage
Acute thrombosis

35. Treatment

36. Treatment Injection treatment Barron’s rubber banding Cryosurgery
Gabriel syringe is filled with sclerosant 5% phenol with almond oil
Barron’s rubber banding
Cryosurgery
Co2 Laser
Lord’s manual dilation

39. Hemorrhoidectomy

40. Stapled Hemorrhoidectomy

42. External Hemorrhoids Perianal Hematoma
Due to rupture of dilated anal vein as result of sever straining.
Sudden onset of painful lump at the anus.
Swelling tense & tender, bluish in colour covered with smooth shining skin.

43. External Hemorrhoids

44. Treatment Evacuation if the patient come within 48hours
If patient come late conservative treatment.
If untreated the haematoma undergoes:
resolution
ulceration
suppuration to forms in abscess
fibrosis which give rise to skin tag.

45. Perianal Abscess
The infection usually starts in one of the crypts of Morgagni and extends along the related anal gland to the intersphincteric plane where it forms as abscess.
Soon it tracks in various directions to produce different types of abscesses .

46. Types of Abscess Perianal abscess (60%) Ischiorectal abscess (30%)
Sub mucous abscess (5%)
Pelvirectal abscess

48. Perianal Abscess
Patient with recurrent anorectal abscess always consider associated underlying diseases such as Crohn’s, UC, rectal cancer and active TB.

49. Perianal Abscess Symptoms Signs Treatment Acute pain High fever
Swelling
Tenderness with induration
Treatment
Incision and drainage and covered by antibiotics.

50. Perianal Abscess

51. Fistula in ano
Defined as track lined by granulation tissues, which connects deeply in the anal canal or rectum and superficially on the skin around the anus.
It usually result from an anorectal abscess.

52. Fistula in ano
Anal fistulas have well recognized association with crohn’s disease, UC, TB, colloid carcinoma of the rectum and lympho granuloma venercum.

54. Types of Anal Fistulas
According to whether their natural opening is below or above the anorectal ring
Low level e.g., subcutaneous, low anal, sub mucous.
High level – open into anal canal at or above the anorectal ring e.g., high anal, pelvirectal

55. Park’s Classification
Inter sphincteric (70%) low level anal fistula
Trans-sphincteric (25%) high level anal fistula
Supra sphincteric fistulae (4%).
Extra sphincteric (1%) rare type include the tract passes outside all sphincter muscles to open in the rectum.

57. Good Sall's Rule
Fistulas with external opening in relation to the anterior ½ of the anus tend to be direct type.

58. Clinical features
Persistent discharge which irritates the skin and causes discomfort at the anus may be associated with pain.
External opening may be seen with palpation the tracks is often palpable as cord.

59. Investigations
Proctoscopy
Radiology
Biopsy

60. Surgery
Fistulectomy

61. Always sent track for biopsy.

62. Seton placement

63. Anal Fissure
Defined as longitudinal tear in the mucosa and skin of the anal canal.
Commonly posterior midline more common in female than male.

64. Anal Fissure
Lateral fissures are so rare there presence suggest specific lesions such as, Crohn’s disease, UC, TB or malignancy.

65. Etiology
Tearing of the anal lining by over distension of the anal canal during passage of large scybalous mass (stool).
Tearing of anal valve or fibrous polyps.
Laceration of the anal canal by sharp FB.
Excessive straining during child birth.

67. Anal Fissure
The acute anal fissure if not treated becomes chronic anal fissures. As result secondary pathological changes may occurs:
Chronicity
A “sentinel” pile
Hypertrophied anal papilla
Contracture of the anus
Suppuration

69. Clinical Features Pain during and after defecation. Constipation
Bleeding
Discharge

70. Findings Fissure or ulcer distal to dentate line. Sentinel Tag
Hypertrophied papilla.
Spasms of the internal sphincter

71. Treatment Conservative Treatment Stool softeners (laxative)
Sitz baths (10 – 15 mins.)
Ointments & Suppository

72. Treatment Surgical Treatment Dilation under anaesthesia (Anal Stretch)
Fissurectomy and dorsal sphincterotomy
Lateral internal sphincterotomy

73. Anorectal Tumours Benign tumours Epithelial Tumours Anal warts (virus)
Juvenile polyp
Adenomatous polyps
Villous papilloma
Familial polyposis
Pseudo polyps
Endometrioma

75. Anorectal Tumours Connective Tissue Tumours Fibrous polyp Lipoma Myoma
Haemangioma
Benign Lymphoma

76. Malignant Tumours of the Anal Canal
The lesion is usually squamous cell carcinoma.
Rarely adenocarcinoma, malignant melanoma or basal cell carcinoma.

77. Squamous cell carcinoma
5% of all anorectal malignancies. Arising from the stratified squamous epithelium of the lower ½ of the anal canal.
It is disease of elderly.
Squamous cell carcinoma more common in males.
The aetiology of anal carcinoma unknown but chronic irritation or infection may be predisposing factors.

79. Clinical Features
Localized ulcer or raised growth with irregular ulcerated surface.
History of bleeding.
History of pain with discomfort.
Tenesmus with incontinence.
Discharge.

80. Examination
On palpation squamous carcinoma feels hard and woody due to invasion of perianal tissues.
P/R examination may prove impossible because of stenosis or discomfort.
Inguinal LN are examined carefully as they receive lymph from the lower anal canal and perianal region and may be the site of metastasis.

81. Treatment Above the pectinate line Abdomino perineal excision
Below the pertinate line
local excision.
If inguinal LN metastasis present should be removed by block dissection.

82. Treatment
Late cases
Palliative colostomy.
Radiotherapy.

83. Rare Malignant Anal Tumours
Adenocarcinoma
Basal cell carcinoma
Malignant melanoma

84. Benign strictures Stricture of the anus and rectum may be: Congenital
Postoperative
Inflammatory

85. Clinical features Progressive difficulty in defecation
In cases of inflammatory strictures
Bleeding
Discharge
Tenesmus
Late cases subacute intestinal obstruction

86. Diagnosis
Rectal examination reveals the location type and degree of the stenosis.
Proctoscopy
Biopsy

87. Treatment
Dilation
Superficial external proctotomy

88. Thanks