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forming acute
angle by pulling it forward:
elt is a wedge-shaped space at each side of anal canal.
& Boundaries :-
e@Medval wall:. Levatory ani &anal canal.
eo Lateral wall:. Obturator intemus, obturater fascia &Pudendal
© Base (inferior) =» Skin- ‘ aaa
= Apex GSupenier):- Tunchon of medial & lat walls.
e Postenior:- Sacrotuberous Ligament.
e Anterior: SuperReial & deep transu. perineal muscles. x
eContents :-
© dense fat.
@ Inferior rectal nerve &vessels.
@ Pudendal rerve &int- pudendal vessels (side pudendal cana), Superior vectal + avec tal
: vein ite \
bevator
‘ant
ebturater
Re akin
bran: obturator
wnternds
Mt Lett
anterie Branch
branch
ost
Po eanch
f ORRHOIDS) "PILes”
Definition: are dieted veins of anal canal. Bly Ke
-enlarged vascular cushions -* chsh 4
= Classically occurs af 3.%.11 clock posi kien Ce
= Ak least 10% of populahon have symphmahc piles. 7
NB: superior rectal vessels CPortal) forms 4 vascular plexus
with middle & inferior rectal vessels C systemic) under the
epithelial Wining of anal canal Called + "Anal Cushions”
maintain Flatass
“7 nucosa inteyeily
i Internal piles: aboue dentate line & covered by mucosa
2-External piles: below dentate Wane & cavered by Ska
oNB :-_External Piles (Peri anal hematoma) :
Presented by Acute Perianal Pain , worse on sithag, walking & delecahon
-Tense , tender blue lump at ccnal vecge-
—May subside spontaneous after 2-2 days , give analgenia.
- iF presented in acute phase incision under LA
3- Mixed : intero external « )
o Usually asymptomatic , unless complicated » Symphms ave:
@ Bleeding per vechim (bright red, painless pusually after
defection) itching. discharge ,(Pain if complicated) ,«
© SIS of complications 4. Prolapse. /ineankinence Crave),
2- Straggulahon. of piles.
3- thrombosis
4 _ Infection &suppuratin.—s Portal
S- gangrene ., tibrosis oe
6- bleecting & anaemia
= The cause ef haemerrhords dp unknown (Primary piles)
but can be Secondary piles
~ Secondary piles are very fare, may caused by pelvic
fumours , pregnany or Portal hypertension, ¢a colon , crohns
- Primary piles ate commen usually due to lew her
det & staining during defecation.
Pathology: “Piscile ctcackce of sageey
of degree: No prolapse , only bleeding Per vechim ,(Dx by preckoseapy)
2204 degree :- Prolapse on defecakon but return spsntanessly.
03d degree: Prolapse on aefecation &has to reduced manually.) 4
0h degree: Prolepsed all the dime Ceannet veduced) i
pet
ent :.
= Good histery and examination
= Investygatten:- Proctoseopy Confirm Piles, sigmoidoscopy te
exclude othe testons (as ca Glan in old pt),
‘0 jatives
= Treatment: off Primary Pilesip t.2 doyree Lite shart en
\ key PY
vubber ligation
Cryosurgury
rth Photecna gulahion
Ace siguye
+B} Secondary Piles: treet undelying cause. Treatment of piles s."foloa™ scuveent
‘Churchil 4 Princple 6
Consevyatiue:-
avoid onshpation & Staining , Pgh Fiber diet , Laxaves
~ Deangestant cream & suppositones “eg anusel supp?
e_Ingecton _scler therapy >.(most used) pe Oe
= inzect 2-3 mt of — F 7%. of Phenol in almond eil “into submusa
absue the pile (net Painfull above dentate ine) , one each Kme
at one week interval .
~ Complications are: O shichie (fibrosis) » alleray -
@ Pain if aeap ing. of bekes dentate
@- submucous abscess
@ Rubber band I'gahon :.
Using a Barron's bander araund pedicle of pile —» ischaemic
anol nectoSis —» separation later on.
e Cryo surguey fe
N20 of Cou
rUSEG lywid nidregen (196%) > caugulating nectosts—asepurmhin.
~Disedvantye —s Prologged emadnd” discharge
0 Phote coagulation :.
nUsing infra-red phetocoggulaten at (100%) > coggulete necrosis
Sucqury + indicated in CIM S906/ shang. les / panpliai
At sth Ceakn’s . Inbleeding
= Haemorrhoidectmy + (rans fixation excision sperahen) Henan
NB:~ prolapsed strangulated piles 4s treated conservabvely,
tin the 17 instance (bed rest, analgesia, ankbiotic ice backs...) |]
but interval heemacchsidectmy if dene later 4e avetol
furkher Problems.
= stapgulated piles are elengerus ,may —y portal pyaemia.
seme surgeon do Alataction of anal canal under GA
te relieve spasm of jafernal sphincter , not usedl arsnadays
called Lord's procedure (frequent Alatahsn 9 cave 60% )«
but recurrance high g may — aaabnence “Fissure in Ano”
Se churchill € Baily
muldapifuldinn! “lear a mcslitine cf aan] tesa} tielgar
dentate line ine capperbed
w= Oceure posterior in ~ For, of eases Cless bleed Supply &
manimum Site of trauma by stool) & 10% anterior.
(mulhple fistaves may be due te Crshn's disease).
e © "Principle of serguey
= Conshpaton with petsage of hard Stool is the mei
Commen seitslayy ° Primay fissure”
= Seandary anal fissure can be caused by
«after delivery
o fatrogenres. speculum , Post haemoreidectmy -
+ Chrons cbsease ,uleembve alih's.
~Superfieal tear
- UHtle inflamm. & oedema
- Spastic internal sphincter
~Mebile base
-No sentnel
- Marked inflamm. & oedema.
~Fibrosed int: sphincter
+ Fixed bese Cby fibrosis
- Senhnel pile.
Pile
~ Sentinel pile: is an vedematous sicin tag at the
lower end of fissure
- Complications ~ — Abscess, f’stula , prunit’s ani -
DID :~ Crohn's , krauma, Ca-> herpes. TB, $, Proriasis
Nehuren perianal hematomns shang: giles.
Pentanue after
- Pain Csherp , during defechon . f aah cons’ padven)
~ Con#pation:~ pain may compel pt te postpone
defecation —» constipation & —» t fyiure
-Bleeding:. streak of blood on sto! + discharge.
~reley symptoms: burning michurahion, dysmenctthsea
o Si9nsr acute Stage : fissure may seen sbut P/R very painful
=Chosaie stage + Prssure seen & palpable +5entinel pile HTreatment
= The ophmal approach is contecvehve in the 1 instance :-
byQwash regimn —»Warm beth with clete) (pe sit in it after defer)
— Anaesthesia: xylecain gel
> Skool Soltner (Laxative)
—> High Rler diet
@ chemical Sphincterotomy» asia:
ng GTN cream (trinttvate)
(v2 oS%) twice daily —rvelax int Sphincter
this tt» healing in Se-Fo% of chronic Fisure but side
effect is headache. diet wicks
= Principles of tucquey & Baily
puce
ir neues Wansenstion
Vhet chal velexahion. mee
~other chemicals at nifedipine , ingecting belulinus toxin
oAeute fissures. main tH ib conseroakues.
- IP failed 4 oigtal dilataton under GA.
eChronic Frssure. main tk IS surgury +.
@- Closed lateral internal _sphinckerstomy :.
= very successiful even in acute fiisure (Bonly tae’)
dene by dividing sat. sphincter at 3 or 3 Ockwk
©. Fissurectomy & Post. int. sphincterrtorpy :-
= excision oP Fissure § sentinel Pile + diweling
inte sphincter posteriacly
- Tt has beames popular receally. — Cealy)
ame He Gandicon QB anal canal 4 pele Yor muruletine
con 8 rtudiedl by +
1 pull though manamedry-
Q- electamys g
5 mapyirg the devel Kengle G anonecla rigg » "Gistules ix Ano”
KDefinition :-
= Abnormal tract Chined by granulation Hiusue) extendiny fram
Skin of perianal region to Cavity of anal canal or rectum.
seAgiticlogy:-
Most arse From neglected perianal abscess
x Pathology ie
clined by grnulehin Hane, usually persist chranveally due fo
1 anal canal act as @ reseruvir for tnfechin-
2- Faecal material may act as a foreyn body.
3- Internal epening of dock allows recurrent infecton achvatin-
4-Undelying speclc diieate C crohns , 18, ulerahve , . ---ek).
ClMSSiFi cation i.
@-Standard classification ».(Park class):
@ tors anal fistulas Their internal pening bel anctectal elgg.
@ High amt fishelas- their ‘ternal pening above anvlectal rig,
@New clasifcaten
Caltmosd all anal Ausulat have their int speniag at dentate line).
@- Lew Indersphincteric Co x):.
= Passes between fat. & ext. sphincters
Q@- low trans-sphencteric (25 2):
~ Passes through ink- dext sphinclece
@- low supra-sphinckeic Cy y) --
~ as sadecsphincteic but enter ichiovectal Rusa
@ High Extra -sphracter'e (47) 1.
as trans -sphinclecic , enter ischorectal forte
and levator ani 4s rectal wall.
- Posterior Fistula C behind tine bet: 3.4 O'leck) open
by a @mman unt speniag in midline (6 dileck) with
curved tracks. : ;
Anterior Pistula open has it's own spenyy & Straight hack mit Pics te
= He previsus perlanal abscess discharge pus.
~ becal Soreness -& pruritis ani, fain if abscess buildup.
=o/e pening seen , palpable cord (tender radurated track)
x Investigation:
~Most fistulae require no fovest. other than a formal
txamiAakon under anaeSthea (EUA) —“Prncited Precke g stg”
= Prochsepy , colensepy + CERCKIT Sher pathelg-
eBintllagnon do tee die decks.
fe
= Fisdalotomy is clone by probing (Probe inserted insicle
Pack unk] bleeds) and laid spen (under GA) —> heals
by granulation tysue kam the base.
- High Fistula CPelwrectl) by two —stage operation
Grenknence may result by damaging paWofectalcs
uthen opening the racic)
NB ® vecurtance
hASy as
of anal Fistula with the best dreatmend
we have # IS glad i anal Ganal and
Fishle eccue fn one of them s¢ may affect sthers ANO-RECTAL. ABSCESS
@-Pumary abscess :~
= Infection of glands by G-ve bacilli —> sndersphicteric
abscess that may spread —ye Down —> Perianal abscess
Sup 9 Pelne abscess \é
+ Medial—y Submawous
a lateral —sischiorectal +
@Secondary abscess.
= IBD (Crohns) , TB, haematoma , cancer, - --ete
ion *
Q@Perianal (607):. sabcutonesus around anus, Pain & toxic 3/5 ast marked-
@ Ischiorectal (30%):. in ischiorectal fossa , if bilateral fossae are
involued —» Horse-shoe abscess , toxic S/S ave marked,
@. Submucus {5 7): dubmacsal, above denbate Wine , Pain, fever severe.
and PIR —» tender boggy swelling Not on sitting.
@ Pelvi-recta) (57);:. above levater ani, may be sccendary to
appendiaitt , diverbradit's ede
se Tieatment »- eset
=Prompt sugical drainage to Prevent Ritula (occure in > 30 % of pl)
(no rule for antbiohics except in dvabetics & immunseampromised ).
SS churchilt
' ery Eg
Definition: chronic. infechon in skin Sinus ee by penetration
of hairs into skin & Sic tissues. sGnmenly in sata) cleft. ene
e Causes: congenital theory: infected dermoid eyst- ea
@ Acquired theory. (mere accepted) 5 lamse hairs renters
inside skin» Pilonidal abscess.
A (eateedigt
Daler
side sinay asmaty
Alvcle ®
#C/P of Pilonidal sinus :-
=Commen in young adult, male » dark wstong hair, black,
loqy sitting Cas Lory dvivers) shad hygien-
GB- may be asymptomatic , usually have clischagg or
acute abscesy (Pain . -ote)
(BID». Perianal fitulae, & abscess
gTreatment t- (Ccherchils)
@. Pllonidal abscess—s inaiion &draingge of pat-
@. Pilonidal sinus :-edersofing the track , rerove hair & Packing
siayect sinus sith methylene blue then do
wide exciim of all tracks Cunt! no dye)
delayed 1°
and either 1° or stitchiry i done
Cie WEL open te head by granulation).
ANAL CARCINOMA ):.
Pathology :. upper Port —> adenscercinoma-
lewer part —s Sg. cell carc’asmn Cmeare commen)
# Spread :. « Direct 22.5 reclum
+ kymph:- upper part (‘tea LN). buler Cagucnal LN)
+ Blood» marly Leer Cin oppar pet), L 8,8.
KC/P ~ bleeding . pruritis, pain , olischege , mass , s/s Q seondag
Ceommen in homosexual) .
Treatment te if non sperable —srack'otherespy.
OM” operable —s osmall lesion do wide local exedion ¢radcothers
alarye lesion do A-P resiechin Cabdomine -Perinen! ¥
aPrognesis:- 52% of pt survive S years.
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