1、Common Office Anorectal Problems,Sandra J. Beck, M.D., FACS, FASCRSAssociate Professor of Colon and Rectal SurgeryUniversity of Kentucky Medical Center,Disclosures,None,Benign Anal Rectal Disease,Anatomy of the anal canal and perianal spacesBenign Anal Rectal DiseaseAbscess and FistulaFissureHemorrh
2、oids,Overview of Anatomy,Anatomy Pelvic and Perirectal SpacesAnatomy of Anal Canal,Retrorectal Space,Waldeyers Fascia,Supralevator Space,Levator Ani Muscle,Deep Postanal Space,Superficial PostanalSpace,Peritoneum,Levator Ani m.,Puborectalis m.,Deep External Sphincter m.,Internal Sphincter m.,Transve
3、rse Septum,SupralevatorSpace,Ischioanal Space,IntersphinctericSpace,Perianal Space,ANAL CANAL,ANAL CANAL,Anal TransitionalZone,Column ofMorgagni,Dentate Line,Anal Crypt,Anal Gland,Anoderm,Diagnosis and Treatment of Anorectal Abscess and Fistula-in-Ano,Anorectal Abscess Etiology,Cryptoglandular absce
4、ssMost commonInfection in the glands at the dentate line Other causesCrohns and Ulcerative ColitisTuberculosis and ActinomycosesMalignancyForeign Bodies, Prostate Surgery or Radiation,Fistula Description,Clock descriptionDoes the anus tell time?Relies on description of patients position: supine, lat
5、eral, prone and relative landmarksAnatomic description: more consistentPubic bone defines anteriorCoccyx define posteriorRight and left*If terms be incorrect, then statements do not accord with facts; and when statements and facts do not accord, then business is not properly executed. Confucius 1,Ta
6、ilbone,Right anterior,Right posterior,Left anterior,Left posterior,Right,Left,Pubic bone,There is an area of induration and erythema in the right posterior quadrant that is likely an abscess that has spontaneously drained,Abscess Classification,Four Types Based on Space InvolvedPerianal - 19-54%Inte
7、rsphincteric - 20-40%Ischioanal - 40-60%Supralevator 2% or less,Most Common,Rare,SupralevatorAbscess,Perianal Abscess,Ischioanal Abscess,IntersphinctericAbscess,SupralevatorSpace,IntersphinctericSpace,Ischioanal Space,HORSESHOE ABSCESS,Anorectal AbscessTreatment of Perianal and Ischiorectal Abscesse
8、s,Diagnosis - usually straightforwardErythema and Pain over affected areaFluctuanceTreatmentIncision and Drainage+/- Excision of small amount of overlying skinInitial packing for hemostasisDrainage catheter (Pezzer) or pack woundAttention to good hygiene and control blood sugarAntibiotics if immunoc
9、ompromised, obese or diabetic,Small Radial incisionShort distance from anus feel for soft spotPlace drain and trim avoids packingFollow up in 7-10 days to remove drain,Catheter Types,Pezzer catheterSolid mushroom top so stays inLess tissue ingrowth,MalecotAllows tissue ingrowthMore painful to remove
10、,Peri anal abscess - ? Antibiotics,Not usually indicated if there is adequate drainageIndicated for patients with:ObesityDiabetesImunocompromisedExtensive large abscess or recurrent abscess,Fistula-in-Ano,Definition abnormal connection between two epithelial surfaces.Classification:Parks: Defines fi
11、stula by course of tractGoodsalls ruleDiagnosisTreatmentGoalsOptions,How does patient present?,May have had a history of abscess History of Crohns diseaseMay present at the same time as abscessComplain of intermittent increase in pain/swelling followed by spontaneous drainageChronic localized area o
12、f irritation or ulcer “pimple near my anus keeps coming back”,Fistula-in-AnoGoodsalls Rule,Posterior,Anterior,Fistula in ano,Fistula in ano: Surgical disease,Refer to Colon and Rectal Surgeon or General SurgeonReassure patient rarely cancer, most do not need a colostomyIf suspect CrohnsGain control
13、of perianal sepsisThen complete full workup and stagingGoals of therapyGet rid of the fistula/connectionPreserve continence,Surgical Options,Primary fistulotomyMainly for low, superficial fistulaRisk of fecal incontinenceFibrin Glue/Fistula PlugUtilizes substrate as scaffold to fill tractDoes not in
14、volve cutting muscleCutting or draining setonsFor deeper tracts that involve significant muscleRisk of fecal incontinenceRectal advancement flapLateral internal fistula transectionNewer procedure. No foreign substrateCuts fistula tract, not muscle,Fistula in ano,Fistula in ano,Fissure in Ano,Definit
15、ion a painful linear ulcer situated in the anal canal and extending from just below the dentate line to the margin of the anusOverlie the lower half of the internal sphincter73.5% are posterior16.4% are anterior2.6% both anterior and posterior,Fissure in AnoPathogenesis,Acute fissure results from tr
16、auma to the anal canal most commonly from a large fecal bolusSecondary changes of chronic fissure includeSentinel pile or skin tag at the distal endHypertrophied anal papilla-swelling, edema and fibrosis near the dentate lineFibrosis of the internal sphincter at the base,Fissure with Sentinel Tag,Fi
17、ssure with Sentinel Tag,Fissure in AnoPathogenesis,Perpetuating factors in chronic fissurePersistent hard bowel movementAbnormal high resting pressure in the internal anal sphincterIncreased pressure in the sphincter causes a decrease in blood flow, preventing healing of the fissure,Fissure in AnoSy
18、mptoms,Pain is the main symptomSharp, cutting or tearing during defecationDuration is few minutes to hoursBleeding bright red and scantSkin Tag Mucous discharge resulting in itching,Fissure in AnoDiagnosis,Diagnosis often made on history aloneInspection gently spread the buttocks and the fissure bec
19、omes apparentTriad of chronic anal fissureSentinel pileHypertrophied anal papillaAnal ulcer,Fissure in AnoDifferential Diagnosis,Intersphincteric abscessPruritus AniFissure from inflammatory bowel diseaseCarcinoma of the anusInfectious Perianal conditionsLeukemic infiltration,Fissure in AnoCrohns An
20、al Fissures,Acute Fissure in AnoTreatment,Increase dietary fiberLocal anesthetic to prevent spasmNitroglycerin or Nifedepine OintmentNot commercially availableMust be mixed by pharmacistWarm tub soaks4-6 weeks of treatment,Chronic Fissure in AnoSurgical Treatment,Indicated on Chronic non-healing ana
21、l fissure and fissure that is refractory to medical therapyLateral Internal SphincterotomyForces the muscle to relaxV-Y Anoplasty flapAllow coverage of fissure with healthy tissue,Hemorrhoids,What are they?Where are they?Why do they become symptomatic?Classification?How do you treat them?Can they be
22、 avoided?,HemorrhoidsWhat are they?,Specialized highly vascular cushions consisting of discrete masses of thick sub mucosa that contain blood vessels, smooth muscle and connective tissueAid in anal continence,HemorrhoidsWhere are they?,Internal Hemorrhoids3 major bundles left lateral, right anterior
23、 and right posteriorAbove the dentate lineBlood drains into the superior rectal vessels then into the portal circulationExternal HemorrhoidsBelow the dentate lineBlood drains through the inferior rectal veins to the pudendal veins on into the iliac veins,HemorrhoidsSymptoms?,Chronic constipationDiar
24、rheaTrauma to the hemorrhoids during defecation cause the most common symptomsPain generally not “knife-like”ItchingBurningBleeding,HemorrhoidsClassification- Internal Hemorrhoids,1st degree bulge into the lumen 2nd degree prolapse with bowel movement but reduce spontaneously3rd degree prolapse spon
25、taneously and require manual reduction4th degree permanently prolapsed hemorrhoids that cannot be reduced,4th Degree Hemorrhoids,HemorrhoidsTreatment Principles,Thorough physical exam to determine severity and rule out other pathologyRefer for surgical evaluation if white or discolored, firm or fixe
26、dDetermine if the problem is internal, external or bothAssess the symptom complex,Treatment,Topical agents: Proctofoam, Anusol HC Analpram, Proctosol creamConservative therapyBulk agents i.e. high fiberFruits, vegetables, oat bran, psylliumIncrease water intakeAvoid caffeinated beveragesAvoid prolon
27、ged sitting on the commodeWarm tub soaks,TreatmentOffice and Minor Procedures,Rubber band ligationPerformed in the officeIndicated for Grade 1 and 2 internal hemorrhoidsBand is applied through an anoscope at the top of an internal hemorrhoidSevere perianal sepsis Classic TriadDelayed anal painUrinar
28、y retentionFever,TreatmentOffice and Minor Procedures,Infrared PhotocoagulationIndicated in 1st degree hemorrhoidsCauses photocoagulation of small vesselsPerformed in office or “Hemorrhoid Relief Center”Minimal pain,Closed HemorrhoidectomyIndication,Hemorrhoids are severely prolapsed and require man
29、ual replacementPatients fail to improve after multiple applications of non-operative treatmentHemorrhoids are complicated by associated pathology such as ulceration, fissure, fistula, large hypertrophied anal papilla or extensive skin tags,Closed HemorrhoidectomyGeneral Principle,Most can be perform
30、ed with local and IV SedationProne/Kraske position is the bestInfuse the area with local anesthetic with epinephrine for hemostasisFleets enema 1-2 hours priorNo antibiotic prophylaxis is necessary,Closed Hemorrhoidectomy,Closed Hemorrhoidectomy,Closed HemorrhoidectomyPost op Result,PPH Stapling Pro
31、cedure for Hemorrhoids,Not for every hemorrhoidIdeal for Grade 2 and 3 with minimal external componentPrevents prolapse and thus less trauma to hemorrhoid with bowel movement,PPH Stapling Procedure for Hemorrhoids,PPH Stapling Procedure for Hemorrhoids,BenefitsLess pain as compared to traditional cl
32、osed hemorrhoidectomyLess blood loss during the procedureLess chance of anal stenosis,PPH Stapling Procedure for Hemorrhoids,RisksIf staple placed too low severe chronic pain and incontinenceIf staple line placed too high failure to relieve symptoms of hemorrhoidsHemorrhoids are not removed so they
33、may continue to bleedPerianal sepsisRectovaginal fistula,Perianal Condyloma,Can sometimes be difficult to distinguish from hemorrhoidsCauliflower type appearanceHistory of HIV, History of abnormal pap smearHomosexual males usually but can be seen in the heterosexual populationCaused by HPV virusIncr
34、eased risk of anal cancer in the immunocompromised patient,Treatment - Topicals,Aldara (Imiquinod) 50% initial responseTopical 5-FU 90% initial responseCondylox (podofilox) Each have high local toxicityPractice Parameters for Anal SquamousNeoplasms www.fascrs.org,Treatment,Photodynamic therapyWide L
35、ocal ExcisionTargeted destruction with cautery and/or Infrared coagulationObservation of AIN I/II with removal of visualized lesionsExcision of AIN III,Anal Squamous AIN,High recurrence rate with all techniquesClose follow up to detect progression to invasive carcinomaAnal pap smear vs high resolution anoscopyOptomize underlying conditions,Questions?,?,
