You are on page 1of 47

Acute perianal conditions

1

Anatomy
2

Anatomy of the anal canal
• The anal canal is
divided into two
unequal sections,
upper and lower:
1) The upper 2/3 : Its
mucosa is lined
by simple columnar
epithelium.
2) The lower 1/3 of the
anal canal is lined
by stratified squamous
epithelium .
3

Blood Supply
• The upper 2/3 of the anal canal:
- is supplied by the superior rectal
artery which is a branch of the inferior
mesenteric artery.
- Is drained by superior rectal vein  inferior
mesenteric vein
• The lower third of the anal canal:
- is supplied by the inferior rectal artery which
is a branch of the internal pudendal artery.
- Inferior rectal vein  internal pudendal vein
4

Physiolog y 5 .

• This function is made by the presence of: 1)Internal sphincter: smooth muscle. 4)Dilated cushions: Hemorrhoids. finest closure. • Resting tone of anal canal is made by: internal sphincter + some external sphincter and levator ani. 6 . 2)External sphincter: skeletal muscle. involuntary. voluntary.Physiology • The function of the anal canal is to maintain continence. 3)Levator ani muscle: voluntary.

Hemorrhoi ds 7 .

Hemorrhoids • Pathophysiology: Engorgement and dilatation of the blood vessels leading to stretching of the overlying mucosa and formation of lumps that may prolapse. 8 .

2) Primary Vs Secondary hemorrhoids. 9 .Hemorrhoids • Classification: 1) Internal Vs External hemorrhoids.

Mixed hemorrhiods: above and below dentate line.External hemorrhiods: below dentate line (External plexus) . 10 .Internal hemorrhiods: above dentate line (internal plexus) .Hemorrhoids • Internal Vs External hemorrhoids: .

Hemorrhoids • Internal Vs External hemorrhoids: -Internal hemorrhoids = columnar epithelium (pink) -External hemorrhoids = Squamous (opaque) 11 .

7.11 o’clock in lithotomy position) 12 .Hemorrhoids • Primary Vs Secondary hemorrhoids: -Primary hemorrhoids: one or more of the main vessels of anal canal are involved (3.

13 .Hemorrhoids • Secondary hemorrhoids: smaller branches are involved • Circumferential hemorrhoids: all around the anal canal  severe condition.

Hemorrhoids • Degrees of hemorrhoids:  1st degree: no prolapse outside (only bleeding)  2nd degree: prolapse. manual reduction  4th degree: permanent prolapse (irreducible) 14 . spontaneous reduction after defecation  3rd degree: prolapse.

 complicated hemorrhoids : Acute sharp pain 15 .Hemorrhoids • Clinical Presentation:  Uncomplicated hemorrhoids: heaviness type of pain after long standing or after defecation.

 Strangulation (strangulated hemorrhoids may become gangrenous and slough off)  Ulceration 16 . . . Some cases may require excision for pain relief.Physical examination: Tender tense blue subcutaneous swelling at anal margin covered by smooth shinny skin.Clinical presentaions : Severe sharp pain in the first 48 hours.Management: Most cases resolve spontaneously within 2 weeks with conservative therapy.Hemorrhoids • Complications:  Thrombosed hemorrhoids. .

Rubber band ligation. 3.  Conservative: High fiber diet + Bulk laxatives  Interventional (non-surgical): 1. .Surgical hemorroidectomy 17 . Sclerosing agent injection. 2.Hemorrhoids • Management It depends on the severity of the case and the response of the patient. Cryosurgery.

Anorectal abscess 18 .

19 . in children. but occurs at all ages. rarely. • .Anorectal abscess • It is a collection of pus in the anal/rectal region.More often in men. • .Common in pts between 20-50 years old.

Formation of (intersphincteric abscess)  This is the starting point of anorectal sepsis.Anorectal abscess Pathophysiology • The most acceptable theory is the cryptoglandular theory: 1. 3. Inflammation in the crypts (cryptitis). Infection spreads through the ducts to the anal gland (glandulitis). 20 . 2.

21 .Anorectal abscess • Clinical presentation:  Throbbing pain.. toxicity.  Systemic symptoms: Fever. which is aggravated by sitting or movement.. malaise.

Anorectal abscess >> If the abscess remains there. >> If the pus goes up above the levator-ani muscle (supra levator abscess) >> If the pus can pass through the external sphincter to the ischiorectal Space (ischiorectal abscess) So the problem starts in the intersphincteric space but it can end 22 anywhere. then the patient will present with intersphincteric abscess. . >> If the pus goes down. the collection will be at the anal verge and the patient will present with a bulge in the perianal skin (perianal abscess).

Anorectal abscess • Physical examination: depends on the site 1. In perianal abscess the perianal skin is red. In ischiorectal abscess it depends on the site: . In supralevator abscess deep pain with little or no outside physical findings.in low level red tender and swollen skin 23 . 2. tender and swollen. 3.in high level little or no external findings . if you do PR examination you'll find a tender mass. 4. In intersphincteric abscess.

Anorectal abscess 24 .

Anorectal abscess • Management:  Incision and drainage Once you decide to drain the abscess. 25 . you have to warn your patient that there is a chance around 50% of recurrence and 50% of fistula formation.

Pilonidal abscess and sinus 26 .

midline openings. 27 .Pilonidal abscess/sinus The term pilonidal sinus describes a condition found in the natal cleft overlying the coccyx. which communicate with a fibrous track lined by granulation tissue and containing hair lying loosely within the lumen. usually non-infected. consisting of one or more.

Hairy . the axilla.Males .long sitting time 28 . midline track. • Risk factors: . so creating a subcutaneous. chronically infected.Pilonidal abscess/sinus • It is thought that the combination of buttock friction and shearing forces in that area allows shed hair or broken hairs which have collected there to drill through the midline skin • OR that infection in relation to a hair follicle allows hair to enter the skin by the suction created by movement of the buttocks. • It may occur in: the umbilicus. the interdigital area in hairdressers.

Intermittent pain especially if inflamed or with superimposed infection.Pilonidal abscess/sinus • Clinical presentation: . .Swelling and discharge 29 .

remove hair Regular Shaving Strict hygiene  Surgical Excision  Acute pilonidal abscess: Usually requires incision and drainage under local anesthesia  Chronic pilonidal sinus: Excision under general anaesthesia with exploration.Pilonidal abscess/sinus • Management:  Conservative Clean the tract. open and removal of tracts 30 .

Anal Fissure 31 .

• Cause: Constipati on Intern al sphinc ter spasm Pain 32 .Anal Fissure • It is a tear in the lower part of the anal canal mucosa.

Anal Fissure 33 .

 Bleeding with defecation.  Mucus discharge  pruritis.  Constipation.Anal Fissure • Clinical presentation:  Severe Pain: associated with defecation. usually resolves spontaneously after a variable time to recur again after the next evacuation. 34 .

Anal Fissure • Classification:  Primary Vs Secondary  Acute Vs Chronic 35 .

Herpes.( IBD .Not at the midline 36 .Unknown cause (cycle) . TB . Leukemia) .Anal Fissure • Primary Vs Secondary:  Primary fissures: .Location: Midline posteriorly 90% Midline anteriorly 10%  Secondary fissures: . Syphilis . HIV .

Distal end of the fissure: Sentinel piles or skin tags 37 .Anal Fissure • Acute Vs Chronic:  Signs of chronicity: . .Proximal end of the fissure: Reactionary polyp (hypertrophied anal papilla) .Deep with a lot of fibrosis.

B) Surgery: .Relieve spasm: Nitroglycerin. high fiber diet and bulk laxatives . . CCB (relax the spasm. sitz baths .Anal Fissure • Management: Cons tipati on Pain Intern al sphin cter spas m  The aim is to break the cycle A) Conservative: . Botulinum toxin. improve blood supply to improve healing).Partial lateral internal sphinctertomy: reduces 38 tightness of the internal sphincter by cutting part of it.Relieve pain: Local analgesics.Treat constipation.

Herpes infection (vesicles) 39 .

40 .(STD) • Very painful.Herpes infection • Sexually transmitted disease. but in late stage we have to wait for the disease to limit by itself. • In early stage we can treat it with antiviral drugs.

Rectal prolapse 41 .

42 .Rectal prolapse • It is the protrusion of wall of rectum through the anus.

bleeding.Pain. especially following a bowel movement.Mainly protrusion of a reddish mass from the anal opening. . • Management: .Rectal prolapse • Clinical presentation: . bulk laxatives .Conservative : high fiber diet .Surgery : abdominal rectopexy 43 . incontinence.

Proctalgia fugax 44 .

sudden explosive 45 . cramp like – Short duration [few minutes] – Disappears spontaneously – May follow stool straining. unrelated to organic diseases [functional GI disorder] • Etiology: – No clear etiology – Probably caused by a spontaneous spasm of the pelvic muscles • Clinical Presentation: Rectal pain – Comes suddenly at night – Severe.• Attacks of severe pain. recur at irregular intervals. arise in the rectum.

inhaled salbutamol has been shown in some studies to reduce their duration. -Warm baths. -Botulinum toxin has been proposed as analgesic. prolonged attacks.• Management: -The most common approach is simply reassurance and topical treatment. -In patients who suffer frequent. medications. .Low dose diazepam at bedtime has been suggested as preventative. 46 . - Relaxation techniques. severe. hot enemas  (if the pain lasts long enough to draw a bath).

The End 47 .