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Other causes:
•Crohn
•TB 60% 5% Ischiorectal
20%
•Carcinoma, Lymphoma and Leukaemia
•Trauma Intersphincteric suprasphincteric
Abscess Treatment
Perianal •Incision and drainge de-roof cavity
•pack with gauze and iodine
Ischio-rectal •IV AB, sitz bath tid, laxitives and anlgesia
•F/U for fistula
Fistula Treatment
Perianal •Fistulotomy vs fistulectomy
Trans/Extra/Supra •Complex treatments using seton
sphincteric
Conservative Surgical
•High fibre diet Lateral sphincterotomy
•Medical
sphincterotomy:
–GTN
–Ca channel blockers
–Butulinum toxins
Pilonidal Sinus
Pathogenesis:
A sinus tract at natal cleft resulting from:
Blockage of hair follicle
Folliculitis
Abscess followed by sinus formation.
Hair trapping
Foreign body reaction
The sinus tract is cephald
Associated with:
Caucasians
Hirsute
Sedentary occupations
Obese
Poor hygeine
Presentation & Treatment
Acute abscess Incision and drainage
Recurrence: 40%
Recurrence: 8-15%
Also found: umbilicus, finger webs, perianal area
History
Age
Hemorrhoids-
common all ages but are uncommon below the age of 20 years.
Perianal haematomata-
occurs at all ages
Fissure-in-ano-(acute)
quite common in children
Anorectal abscess-
common between the ages of 20 and 50 years.
Pilonidal sinus-
rare before puberty and in people over 40 years.
History
Sex
Hemorrhoids-
common in both sexs
Perianal haematomata-
occurs at all ages
Fissure-in-ano-
common in men
Anorectal abscess-
more common in men
Pilonidal sinus-
more common in men
Prolapse of rectum-
more common in women
History
Principal symptoms of rectal and anal conditions:
Bleeding
Pain
Tenesmus
Change in bowel habit
Change in the stool
Discharge
pruritis
History - Bleeding
Can be fresh or altered
Example of altered is melaena
Black tarry stool
Recognizable blood may appear in four ways:
Mixed with faeces
On the surface of the faeces
Separate from the faeces: after/unrelated to defaecation
On the toilet paper after cleaning
History - Bleeding
Diagnosis of anal conditions which present with
rectal bleeding
Bleeding but no pain:
Blood mixed with stool = ca of colon
Blood streaked on stool = ca of rectum
Blood after defaecation = hemorrhoids
Blood and mucus = colitis
Bleeding + pain = fissure or carcinoma of anal canal
The most common causes of rectal bleeding in patients who visit primary care
physicians are hemorrhoids, fissures and polyps.
History – Anal pain
Diagnosis of anal conditions which
present with pain
Pain alone
Fissure ( pain after defaction)
Proctalgia fugax (pain spontaneously at night)
Anorectal abscess
Pain with bleeding
Fissure
Pain with a lump
Perianal haematoma
Anorectal abscess
Pain, lump and bleeding
Prolapsed haemorrhoids/rectum
Carcinoma of the anal canal
Anorectal examination
One of the most important examinations in a patient with abdominal
disease.
Still its the least popular segment of the entire physical examination.
Should not be omitted from your examination, especially in middle-aged
and older patient, why?
risks missing an asymptomatic carcinooma
Can be done in numerous positions:
Left Lateral (Sims’) position. The usual position when the patient is in bed.
Turn patient on to left side with pelvis vertical. Ask patients to draw knees up
to chest with buttocks on the side of the couch
The Knee-elbow position. Patient kneeling on couch, resting on elbows, of
particular use when palpating the prostate and seminal
The Dorsal Position. This position with the patient lying on the back with
right leg flexed is useful when the patient is in severe pain, and movement is
contra-indicated. Enables assessment of rectovesical pouch in abdominal
emergencies.
Lithotomy. best position for examination but not always available.
Anorectal examination
External inspection:
Piles.
Skin tags (normal, Crohn's, hemorhoids).
Rectal prolapse.
Anal fissure.
Fistula.
Anal warts.
Carcinoma.
Signs of incontinence, diarrhea.
External inspection (straining):
Ask pt. to strain.
Rectal prolapse upon straining.
Hemorrhoid prolapse.
Incontinence.
Ask if straining is painful
Anorectal examination
palpation
Lubricate index finger.
Insert finger slowly, assessing external sphincter tone as
enter.
Male: palpate prostate [anterior of rectum]:
• Hard nodule (prostate cancer).
• Tender (prostatitis).
Female: palpate cervix [anterior of rectum]:
• Mass in pouch of Douglas.
Rotate finger, palpating along left, posterior, right walls.
Withdraw finger.
Wipe lubricant off pt.
Ask if was significant pain during examination.
Anorectal examination
Inspect withdrawn fingertip for:
Blood, melaena
Stool color
Pus
Mucous.
Treatment :
* Treating the underlying condition
* In children, Conservative treatment
* The rectal mass may be returned to the rectum manually
* Surgical correction for complete rectal prolapse
Complications
* Constipation
* Malnutrition or malabsorption
* Other complications of underlying condition
Proctitis
An inflammation of the rectum causing discomfort, bleeding, and
occasionally, a discharge of mucus or pus, And the anus may also be
involved.
Causes:
* Sexually-transmitted diseases(gonorrhea, herpes, Syphilis
,chlamydia, and lymphogranuloma venereum.
* Non-sexually transmitted infections( Beta-hemolytic
streptococcus , Amoebic dysentry, Bilharzial dysentry)
*Autoimmune diseases (Ulcerative colitis and crohn’s disease)
* Tuberculous proctitis
* AIDS
*Radiation Proctitis
* noxious agents
Proctitis
Symptoms:
pain, discomfort
rectal bleeding
rectal discharge, pus
stools, bloody
constipation
Tenesmus
*Tests:
proctoscopy
sigmoidoscopy
rectal culture
Proctitis
Treatment: treatment of the underlying cause usually
cures the problem. Proctitis caused by infection is
treated with antibiotics specific for the causative
organism. Corticosteroid or mesalamine suppositories
may relieve symptoms in Crohn's disease or ulcerative
colitis.
Benign tumours of the rectum
(POLYPS)
A polyp is a lesion that projects into the lumen
Polyps are commonly found
in vascular organs
Polyps bleed easily
The rectum and sigmoid colon
are common sites of polyps
Symptoms and signs of polyps
* passage of blood and
mucus PR
* Rarely obstruction or
intussusception
Types of Polyps
Juvenile Polyps
Commonest form of polyps in children
Are red pedunculated spheres lesions
Can occur throughout large bowel but are most
common in the rectum
Usually present before 12 years
Present with Prolapsing lump or rectal bleeding
Have little malignant potential
Treated by local endoscopic resection
Adenomatous Polyps
Are pedunculated lesions
Mainly occur in the rectum and sigmoid colon
Are often asymptomatic but may produce
anaemia from chronic occult bleeding
May give rise to crampy pain
May secrete mucus
Have malignant potential
Treated by colonoscopic polypectomy
Villous Papillomas
Are flat, sessile lesions within the rectum
Secrete copious amount of mucus producing
spurious diarrhoea
Present with hypokalemia
Significant risk of malignant change
Treated by transanal excision of complete lesion
If lesion is extensive, mucosal proctectomy and
coloanal anastomosis should be done
Familial Polyposis
Is an autosomal dominant syndrome diagnosed
when a patient has more than 100 adenomatous
polyps
Due to mutation on long arm of chromosome 5
May be asymptomatic but bleeding,, abdominal pain and
diarrhoea are all likely symptoms
The risk of devoloping carcinoma is virtually 100%
within 15 years
The most appropriate treatment is panproctocolectomy
with ileal pouch-anal anastomosis
Questions