RECTUM

ANNA JOE
ANNET MARY MATHEW
ANU JISMON
8th SEMESTER
RECTUM - BENIGN
CONDITIONSRECTAL PROLAPSE
ANAL FISSUREPILESANAL FISTULA
ANATOMY OF RECTUM:
Distal portion of the large gut in the posterior pelvis
placed between the sigmoid colon above and anal canal
below
Placed infront of last three pieces of sacrum & coccyx
Rectosigmoid junction is 15cm from the anal verge
3 cardinal features of large intestine
{sacculation/hausration, appendices epiploicae &
taeniae} are absent
Internal anal sphincter: involuntary smooth muscle ,
formed by downward extension of circular muscle of
rectum , under control of autonomic nervous system.
It is in a tonic state of contraction.
External anal sphincter: surrounds the internal & continuous with
levator ani muscle, supplied by pudendal nerve
Divided into.deep
superficial
subcutaneous
By the lateral extension of longitudinal muscle layer.
 ARTERIAL SUPPLY
Superior rectal artery
(branch of inferior mescentric artery)
Middle rectal artery
(branch of internal iliac artery)
Inferior rectal artery
(branch of internal iliac artery)
VENOUS SYSTEM
2 directions
Superior haemarrhoidal vein which
drain the anal canal above the
Dentate line pass upwards to
continue as rectal vein
Upwards drain into superior rectal
veins, then into inferior mesenteric
veins and then into the portal
system
Across into the middle rectal vein,
and then into the internal iliac veins
PERITONEAL
COVERING
Upper 1/3rd is covered by
peritoneum in front and lateral
aspect
Middle 1/3rd is covered by
peritoneum in anterior aspects
only
Lower 1/3rd has no covering but
has two fascia
- Waldeyer’s fascia
- Denonvillier’s fascia
NERVE SUPPLY
Sympathetic : fibres come from the hypogastric plexus,
which is located at the aortic bifurcation at the level of
L5.
Parasympathetic : S2, S3, S4 supply motor fibres to
the detrusor.
External anal sphincter and puborectalis are innervated
by inferior rectal branches of internal pudendal nerve
IMPORTANCE OF RECTUM
About 1/3rd of the patients coming to OPD suffer from rectal diseases
due to bad food habits.
It an organ where feces is stored.
PILES OR HAEMORRHOIDS
PILES or HAEMORRHOIDS
Anal cushion- aggregation of blood vessels, smooth
muscles & elastic connective tissue in the submucosa
Downward sliding of anal cushions abnormally due to
straining or other causes
Piles can be mucosal or vascular
Types; Internal- above the dentate line covered with
mucus membrane
External-below the dentate line covered with skin
Internoexternal- occurs together
CLASSIFICATION 1
PRIMARY HAEMORRHOIDS- located at 3,7, 11’o clock
position, related to superior haemorrhoidal vessel
SECONDARY HAEMORRHOIDS- occurs between the
primary sites
CLASSIFICATION 2
1ST DEGREE
Piles within that may bleed but does not come out.
2nd DEGREE
Piles that prolapse during defecation but returns back spontaneously.
3rd DEGREE
Piles prolapsed during defecation but can be replaced back by only
manual help
4rth DEGREE
Piles that are permanently prolapsed.
AETIOLOGY
Heriditary
Morphological- weight of the blood column without valves
causes high pressure & more congestion
Other causes- Straining, diarrhoea, constipation, hard stool, low
fibre diet, overpurgation, CA rectum
Pregnancy- raised progesterone relaxes venous wall & reduces its
tone, enlarged uterus compresses the pelvic vein
Bulging of haemorrhoidal plexuses{anal corpus cavernosum} due
to raised luminal pressure & transmission of arterial pressure
CLINICAL FEATURES
Mostly between 30 – 65 yrs of age
Bleeding: 1st symptom- Splash in the pan like, bright red
& fresh, occurs during defecation
Mass per anum
Anaemia- secondary
Mucoid discharge
Pain due to prolapse, infection or spasm
It may also lead to

Profuse haemorrhage
Strangulation
Thrombosis
Ulceration
Gangrene
Fibrosis
Suppuration, leads to perianal abscess
 On inspection prolapsed piles will be visualized only in 3rd and 4th
degree
On P/R examination- only thrombosed piles can be felt
Proctoscopy- exact position can be made out
Numbers,degree and size
Surface and appearance of piles
Features,chronicity of prolapse
Also look for other rectal lesion such as external tags,anal papillae
and fissure

Sigmoidoscopy/ colonoscopy/ barium enema- to rule out malignancy

DD- rectal prolapse, rectalpolyp, perianal warts

INVESTIGATIONS
Haematocrit to rule out other causes of
Colonoscopy bleeding per anum
Barium enema X ray
 TREATMENT
1st degree

a.CONSERVATIVE:Fibre diet 35g/day, plenty of water,

b. MEDICAL
Local applications to reduce pain, itching & edema
Sitzbath- patient sit in warm water with anal region
dipped in water for 20 mins, 2-3 times a day
laxatives: lactulose solution to soften the bowel
Analgesics
2nd degree
Lifestyle changes
Banding
sclerotherapy
 BARRON’S BANDING:
Done for 2nd degree piles
Causes ischemic necrosis and piles fall off
At a time only two piles can be banded
Done without anaesthesia
Usually two bands are used to take care of breakage
Tissue sloughs off in 1- 2 weeks leaving an ulcer which
heals by scarring
Sclerotherapy:
OP procedure, done in 2nd degree piles
Drugs used: 5% phenol in almond oil
Site: Submucosal plane just above the anorectal ring
Contraindications: thrombosed or prolapsed piles
presence of fistula or fissures
pregnancy or diabetes mellitus
Complications: recurrence, tenesmus, ulceration,
submucosal abscess, anal canal pain
3rd degree
Lifestyle changes
Sclerotherapy
Banding
SURGERY
4TH DEGREE
SURGERY
SURGERIES
OPEN HEMORRHOIDECTOMY:MILLIGAN MORGAN
CLOSED HEMORHOIDECTOMY:FERGUSON
STAPLED HEMORHOIDOPEXY:PROCEDURE OF CHOICE
 Stapled haemorrhoidopexy:
Circumferential exicision of the mucosa & submucosa just
above the dendate line using circular haemorrhoidal
stapler
Advantages: less painfull, less blood loss, faster recovery,
short hospital stay
Disadvantage: injury to anal spincter, haemorrhage
Contraindications: fissure & fistula
 CRYO SURGERY:
Nitrous oxide(-98°) or liquid nitrogen (-196°) used to
coagulate &cause necrosis of piles which falls off
subsequently , painless , carried out with the help of
cryoprobe
Method:
patient is put in lithotomy position
Cryoprobe applied in the longitudinal axis of internal pile
above the dentate line
Pressure maintained above 700Ib
Rapid adhesion with freezing occurs
Traction & slight rotation in both direction done to draw
entire pile mass to come in contact with probe
entire tissue is frozen in 20- 30 sec , probe is detached
after warming (defrosting)
Advantages:
painless , simple , safe , can be done in OP with less
bleeding
Disadvantages:
Profuse watery discharge , itching , pain if skin is
frozen
 Infrared coagulation:
Heat used to burn the piles so as to allow it to fall off
Specific infrared wavelengths produce chemical changes
that causes blood coagulation within the haemorrhoids
itself, which causes the haemorrhoid to seal, shrivel,
shrink or slough off
 Doppler guided haemorrhoidal artery ligation:
Painless 20min procedure that cures all degrees of
haemorrhoids by blocking blood supply of piles
Advantages: anaesthesia not needed, blood loss & pain
are minimal, safe in diabetic, cardiac, oldage & pregnancy
 Laser therapy for piles- for 3rd degree internal
haemorrhoids
Advantages: less operative time, less postoperative bleed
& pain, rapid healing, less complications
Disadvantages: needs skill, secondary hemorrhage &
injury to spincter can occur
ANAL FISSURE
ANAL FISSURE
It is an ulcer in the longitudinal axis of the lower anal canal
Commonly occurs in midline posteriorly
Superficial , small but distressing lesion
Ends above dentate line
CAUSES:
Because of the curvature of sacrum and rectum hard fecal matter
while passing down causes a tear in the anal valve leading to
post. Anal fissure
Ant. Anal fissure is common in females due to lack of support to
pelvic floor
Hard stool, diarrohea , increased sphincter tone , local
ischaemia , trauma , STD
Types- ANAL FISSURE

1. ACUTE ANAL FISSURE

Deep tear in the lower anal skin with severe sphincter spasm
without oedema or inflammation
Presents with severe pain and constipation
2.CHRONIC ANAL FISSURE
Inflammed indurated margin with scar tissue
Inferior margin of ulcer is odematous acts like guard – sentinel pile
Proximally hypertrophied anal papillae is observed
Can cause repeated infection – fibrosis – abscess formation – fistula
formation
Less painfull
Clinical features:
Common in middle aged women
Pain is severe in acute type
Constipation , bleeding , discharge
In chronic fissure ulcer felt with button like depression ,
induration
DD: CA anal canal, Venereal disease, Tuberculous ulcer
Treatment
Acute anal fissure:
CONSERVATIVE MANAGEMENT
Laxatives,addition of fibre to diet,stool softeners
Warm bath,topical local anaesthetic(xylocaine)
Stretching of the anal canal using two fingers of each
hands under anaesthesia
Chronic anal fissure :
MEDICAL MANAGEMENT
Diltiazem 2%, L arginine
Topical nitroglycerin 0.2% use to relax sphincter
Botulinum toxin 25units inj into the internal sphincter –
reduces tone , improves blood supply, controls ischaemia

SURGICAL MANAGEMENT
Lateral anal sphincterotomy ; internal sphincter is
divided partially away from the fissure either in right or
left in lateral position
Anal advancement flap
Dorsal fissurectomy with sphincterotomy
Biopsy is done to rule out carcinoma , tuberculosis
FISTULA- IN - ANO
 The dentate line – 2 cm proximal to anal verge
=> important landmark in fistula-in-ano. These glands secrete
mucus to lubricate anus, and are source of infection. Infection of
these intersphincteric gland that initiate fistual-in-ano
Abnormal communication between anal canal and rectum
with exterior (Perianal Skin)
Track lined by granulation tissue
Usually occurs in pre-existing anorectal abscess which burst
spontaneously
Aetiopathogenesis:
Fistula-in-ano can be cryptoglandular, non-
cryptoglandular
=> cryptoglandular hypothesis.
Occurred due to persistent
anal gland infection

Acute anorectal abscess

Development of fistula-in-
ano
Causes:
LOW LEVEL FISTULA HIGH LEVEL FISTULA
Lymphogranuloma Venereum Tuberculosis
Hydradenitis Suppurativa Ulcerative colitis
Carcinoma
Crohn’s disease
trauma
Classification
LOW LEVEL FISTULA
These open into anal canal below internal ring
HIGH LEVEL FISTULA
These open into anal canal at or above internal ring.
Low level fistula
Clinical Features
Common in young adults male
Persistant seropurulent discharge, keeps the part always wet
Previous history of anal gland infection, with recurrent abscess
External opening can be single/multiple, with sprouting
granulation tissue, may discharge blood
Clinical Features
Internal opening in carcinomo felt as a ‘buttonhole’
defect inside the rectum.
Ischiorectal fossa on each side, most often
communicates with each other behind the anus
causing horseshoe fistula
Clinical Features
Goodsall’s Rule: A fistula with an external opening
in the anterior half of anus within 3.75cm tends to
be direct type and in the posterior half indirect type
or curved and sometimes horse-shoe type. It may
communicate with opposite
Investigations:
Fistulogram (Only under anaesthesia)
MRI/MRI Fistulogram
Endorectal ultrasound- assess deeper plane
Colonoscopy often when ulcerative colitis is suspected
Specific blood test ..mantoux test
Chest X-ray, ESR, Barium enema X-ray
Discharge Study, biopsy
 TREATMENT
1) FISTULOTOMY:

Indicated in low fistula

Probe is passed through the external
opening into the rectum and along the
length of this tract the fistula is laid
open( under anaesthasia)
Wound is left open and allow to heal by
granulation tissue (Marsupialisation)
Intersphincteric and low transsphincteric
fistulas of recent origin are treated by this
2) FISTULECTOMY:

Treat chronic fistula

Excising the entire fibrous tissue and
track
Wound is kept open
Done for Posterior semi horse-shoe
and horse-shoe fistula
3)FISTULECTOMY WITH OR WITHOUT
COLOSTOMY
4) Advanced flaps are used- Mucosal flap
procedure
5) Gluing of fistula track
6) Anal fistula plug (AFP) repair:
Surgisis anal fistula plug is used, contains
naturally derived extra cellular matrix act as
scaffolding, ingrowth of tissue, remodelling
NEWER TECHNIQUES
LIFT Technique (ligation of intersphincteric
fistula track)

Under anaesthasia in lithotomy position

Make a transverse incision
Fistula identified and ligated
Part is excised, outer part is curetted
through external opening
VAAFT Procedure (Video assisted anal fistula
track ligation):

Find specialised endoscope is passed through

the outer opening into the fistula track
With continuous irrigation
Wall is cauterized
Inner opening is ligated
Fistula clip closure

Closure of the internal fistula opening

with a super elastic clip made of nitinol.
Treatment of high level fistula
Staged procedure- initial colostomy is
done followed by definite procedure
Definitive procedure..fistulectomy
Seton Technique: Thread passed through
the entire tract and both end are tied and
tightened once a week so that by 6 weeks
it cuts through
Later closure of colostomy
RECTAL PROLAPSE
RECTAL PROLAPSE
Circumferential descent of rectum through anal
canal.
Common in infants, children & elderly
It can be: Partial
Complete
 TYPES
PARTIAL RECTAL PROLAPSE:
only mucosa & submucosa of rectum descends, not
more than 3.75cm, no descend of the muscular layer,
commonest type
Clinical features: H/O mass per anum observed when
child is allowed to strain in squatting position
pink in colour & circumferential
DD: Piles; blue colour & non-circumferential
Treatment:
CONSERVATIVE
nutrition improved, constipation corrected
MEDICAL
submucosal injection of 10ml of 5% phenol in almond
oil
alternate 30ml tetracycline or hypertonic saline
SURGICAL
Goodsall’s operation- excision of prolapsed mucosa at
its base
Stapled transanal rectal recession surgery {STARR}
digital repositioning
COMPLETE RECTAL PROLAPSE
Also known as procidentia
Common in females
It is due to weakened levator ani & supporting pelvic
tissues
Descend more than 3.75cm
Includes muscular layer
Often associated with uterine descent
Clinical features:
concentric , red in colour , usually reducible painless
mass , fecal incontinence , bleeding , sepsis discharge ,
fever , anaemia
Per rectal examination shows lax sphincter
DD: rectosigmoid intussusception, 3rd degree piles(non
concentric plum coloured) , large rectal polyp
AETIOLOGY
Chronic constipation with constant straining
Children- Diarrhoea, cough, malnutrition
Infants- Decreased sacral curvature & decreased anal
canal tone
Females- repeated birth injuries to perineum
{multipara}
Other causes: reduced ischiorectal fossa fat, poorly
developed pelvis, pudendal nerve damage due
diabetes, obstetric injury
COMPLICATIONS OF RECTAL PROLAPSE
Ulceration, bleeding , anaemia
Irreducibility, gangrene
Proctitis , sepsis
Rupture with evisceration
 Investigations:
Sigmoidoscopy: detect the tumour in the
intussuscepted prolapsed rectum
OTHERS
Defecography,- reveals increased mobility of rectum
from sacral fixation point with redundant mesorectum
& funnel formation, fluoroscopic
Anal manometry:Resting(40mmHg internal sphincter) &
squeeze (80mmHg external sphincter) measures at
various points of anal canal.
In prolapse ,pressure decreases
Pudendal nerve latency :normal 1.8-2.2 msec ,
prolonged in pudendal nerve damage
 Treatment:
PERINEAL APPROACH
1.ALTEMEIER PROCEDURE
Full thickness resection is performed and restoration of
colorectal continuity by stapled anastomosis.
Procedure of choice in patients with incarcerated and
strangulated prolapse.

1. DELORME’S OPERATION
Rectal muosa is stripped circumferentially
Underlying muscle is plicated with series of suture
Disadvantage:recurrence rate high
1. THIERSCH OPERATION
steel wire or nylon tape is placed around anal canal
Complication:stenosis,perineal sepsis,obstructed defecation
 ABDOMINAL APPROACH
1. LAPROSCOPIC MESH RECTOPEXY
POSTERIOR RECTOPEXY
Mesh between rectum and sacrum and sutured to sacrum using non
absorbable suture.
ANTERIOR RECTOPEXY
Plane is created between rectum and vagina
Strip of mesh sutured to the anterior rectum and posterior vaginal wall
Only possible in females.
Well’s operation:
Polyvinyl alcohol sponge is wrapped around the
mobilised rectum & is fixed to sacrum
Ripstein operation:
After mobilisation of the rectum, 5cm width Teflon
mesh sling is passed around the rectum to fix it behind
the fascia 5cm below and in front of thesacral
promontory
 Lahaut’s operation:
Extraperitonialisation is done to pull the rectus forward to prevent
descend
Complications of surgery:
Injury to hypogastric nerve
Bladder dysfunction
Recurrence of prolapse
Infections
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