Anal Rectal Diseases

dr. Ade Tan Reza,Sp.B

 Perianal Fistula and Abscess
Perianal abscess almost always arise 5%
from a fistulous tract. It is an infection of
the soft tissue surrounding the anus.

Aetiology & Pathogenesis:

•4-10 glands at dentate line.
•Infection of the cryptglandular epithelium
resulting from obstruction of the glands.
•Ascending infection into the intersphincteric
space and other potential spaces.
•Bacteria implicated:
E.Coli., Enterococci, bacteroides

Other causes:
•Crohn
•TB 60% 5% Ischiorectal
20%
•Carcinoma, Lymphoma and Leukaemia
•Trauma Intersphincteric suprasphincteric

•Inflammatory pelvic conditions (appendicitis) Trans-sphincteric extrasphincteric

 Pathophysiology

Glandular secretion Infection &

stasis suppuration

Anal crypts abscess

obstruction formation
Perianal Abscess
 Perianal Abscess
Clinical presentation

Abscess Clinical presentation

Perianal •Perianal pain, discharge (pus) and fever
•Tender, fluctuant, erythematous subcutaneous
lump
Ischio-rectal •Chills, fever, ischiorectal pain
•Indurated, erythematous mss, tender
Intersphincteric •Rectal pain, chills and fever, discharge
Supralevator •PR tender. Difficult to identify are. EUA needed
 Peri-anal Fistula
Clinical presentation
 Follow 40-60% of perianal Godsalls law
abscess and cryptgland
Anterior: drain straight
infections
Posterior: drain curved to anorectal
midline
 Presentation:
 External openings
 Purulent discharge
 Blood
 Perianal pain

Also associated with:

•IBD
•Malignancy
•TB/ Actinomycosis
•Diverticular disease
 Perianal Abscess
Management
Aim: adequate drainage of abscess
preservation of sphincter function

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

Intersphincteric •I&D through interspgincteric plane.

Supralevator •Treat the underlying cause

* Preop: full lab evaluation

*Always perform Examination under GA ( EUA) and obtain a biopsy.
 Perianal fistula
Managment
Aim: Define anatomy
Eliminate tract
preservation of sphincter function

Fistula Treatment
Perianal •Fistulotomy vs fistulectomy
Trans/Extra/Supra •Complex treatments using seton
sphincteric

* Preop: full lab evaluation

*Always perform Examination under GA ( EUA) and obtain a biopsy.
 Anal Fissure
 Linear tears in the anal mucosa exposing the internal sphincter
 90% are posterior
 Caused mainly by trauma ( hard Stool). Followed by increased
sphincter tone and ischemia.
 Other causes: IBD, Ca, Chronic infections
 Anal Fissure
Clinical Assessment

Acute Chronic

•Sever acute •Pain mild to

pain moderate
•Fresh blood •More than 6
spotting weeks
•Clean linear •Hypertrophied
tear. Int.sphincter
•Skin tag
•Granulation
around the
edge
 Anal Fissure
Treatment

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%

Chronic Pain and Wide local excision

discharge • with primary closure or
• closure by secondary
intension

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.
• Other examination would be systemically preformed
and depends on the case you have e.g swelling such
as anorectal abscess or ulcers.
Acute Ano-rectal Conditions
 Rectal prolapse
• Rectal prolapse is the abnormal movement of the rectal mucosa
down to or through the anal opening.

Mucosal prolapse Complete rectal prolapse

 Rectal prolapse
• Mucosal prolapse is more often seen in children below 3 yrs of age
following an attack of diarrhoea or whooping cough , and if it occurs
in adult is usually associated with haemrrhoids.
• Complete rectal prolapse is seen more commonly in elderly women
who have a habit of excessive straining during defecation.
• Rectal prolapse is often associated with other conditions such as:
* Pinworms(Enterobiasis)
* Cystic fibrosis
* Malnutrition and malabsorption (Celiac disease)
* Constipation
* Prior trauma to the anus or pelvic area
 Rectal prolapse
• Symptoms:The main symptom is a protrusion of a reddish mass from the anal
opening, especially following a bowel movement.

• 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