PERI-ANAL CONDITIONS

Dr Temesgen K.
(G. Surgeon, Assisstant Professor)
 Important Anatomy
• Anatomic anal canal - extends from the
dentate/pectinate line to the anal verge.
• The anal transition zone includes mucosa
proximal to the dentate line that shares
histologic characteristics of columnar,
cuboidal, and squamous epithelium
• The surgical anal canal - measures 2 to 4 cm
in length and is generally longer in men than
in women.
• It begins at the anorectal junction and
terminates at the anal verge.
1. Hemorrhoids
2. Anorectal Abscess
3. Fistula in ano
4. Anal fissure
5. Rectal proplapse
 Hemorrhoids
• Definition :dilated and engorged
vascular pedicles in the
hemorrhoid tissue
Classification :
• Internal :above the dentate line
• External :below the dentate line
• Intero-external
 Internal hemorrhoids
• Incidence :4 % to 80 % ,age 45-65
• Arranged in three groups (3, 7 ,11 o’clock)
Clinical feature
• Painless bleeding P/E
• Prolapse •Prolapsed tissue
• Mucus discharge •DRE
• Itching •proctoscopy
Internal hemorrhoids
 Complications
• Bleeding
• Strangulation
• Thrombosis
• Gangrene
• Suppuration
• pylephlebitis
• Ulceration
• Fibrosis
 Treatment
1. Non-operative : avoidance of straining
stool softeners ,creams, suppositories
2. Scelerotherapy :First & second degree
3. Banding Rx :second degree
4. Hemorroidectomy
• Open (Milligan-Morgan)
• Closed (Fergusson)
 Postoperative complications
• Early • Late
• Pain • Hemorrhage
• Urinary retention • Anal stenosis
• Fecal impaction • Ana fissure
• Hemorrhage
• Sphincter injury
• Infection
 Thrombosed External
hemorrhoids
Clinical feature
• Sudden onset severe pain
• Tense & tender swelling in the anal
• verge
Natural course
• Resolution is common
• Suppuration
• Fibrosis ►skin tag is common
• Burst and extrude clot or continue
• bleeding
 Thrombosed External
hemorrhoids
Treatment
• Early (with in 36 hrs)
Excision under LA
Late
o Conservative mx
o Recurrence rate is 50 %
 Anorectal abscess
• Are suppuratibve infection around the anal canal
Etiology
• > 90 % originates from infection of anal glands
• Other causes
o Hematogenous
o Extension of boil
o Neoplasm
o Inflammatory bowel disease
o Immunosuppression :AIDS and DM
 Anorectal abscess

Classification
o Perianal (60 %)
o Ischiorectal (30 %)
o Submucus (5 %)
o Pelvirectal (<5 %)
Anorectal abscess
 Anorectal abscess
Clinical features
• Severe & continuous anal pain
• Constitutional symptoms
• Tender cystic mass
Treatment
• Drainage (cure rate is 50 %)
o Perianal & ischiorectal :incision over the perianal skin
overlying the abscess
o Pelvirectal : transanal incision over the abscess
• Antibiotics( for immunocompromized pts)
 Fistula in ano
• Def: A track lined by granulation tissue that connects the
anal canal or rectum to skin around the anus

Causes
• Anorectal abscess which bursts spontaneously or was
opened inadequately
• Granulomatous lesions :Tb, Crohn’s dis.,
actinomycosis (multiple external openings)
• Carcinoma

❖ Chronic fistula may be complicated by colloid carcinoma

Parks’ classification
Fistula in ano
 Fistula in ano
Diagnosis
o Persistent purulent drainage
o Palpable indurated tract & external openings
o Internal opening detected by palpation or
proctoscopy
• Probing
• Injections of methylene blue/hydrogen
peroxide
• Goodsall’a rule as a guide to locate the
internal opening
 Fistula in ano
Investigation
• Fistulography
• Endoluminal ultrasound
• MRI
• CXR (pulmonary Tb)
 Fistula in ano
Treatment of low level fistula
• Preop care :cleansing enema ,laxatives
• Intraoperative :bidigital
examination ,probing ,injection of hydrogen peroxide
Technique
• Fistulotomy ,curettage
• Biopsy from the track
• Post operative :sitz bath ,antibiotics, anal
dilatation
 Fistula in ano
Treatment of High level fistula
• Staged operations with primary colostomy
• Seton method ( a ligature of silk, nylon, silastic
or linen)
Types
• cutting :drain, cuts the muscle to allow fibrosis
with no muscle defect
• non-cutting (loose) :drain
Fistula in ano …
 Anal fissure
• Elongated ulcer in lower anal canal below dentate line
Location
o Midline posterior (90 %)
o Midline anterior (10 %)
Etiology
• Pressure of a hard fecal mass on posterior anal tissues
stretching of epithelium
• Ischemia
Other causes
• Posthemorrhoidectomy
• Inflammatory bowel disease (multiple fissures & atypical
position)
• Sexually transmitted diseases
 Pathology
• Acute anal fissure
o Little indurations or edema of its edges
o Spasm of internal sphincter
• Chronic anal fissure
o Indurated margins ,a base consisting of either scar or internal
sphincter
o Skin tag at lower end
o Spasm of anal sphincter
• Biopsy is recommended
 Anal fissure
• Common in women in middle age
D/dx
• Anal cancer
• Tuberculosis
• STDS (Herpes ,HIV)
 Anal fissure
Clinical features
• Pain on defecation
• Constipation
• Minimal bright red bleeding
• Mucus discharge
• Skin tag
• Ulcer may be seen
• DRE with xylocain
 Anal fissure
Treatment
1. Conservative treatment
2.Stool softeners ,local anesthetic jelly and anal
dilators
3.Nitrates ointments
2. Anal dilatation under GA (Lord’s
procedure)
3. Lateral anal sphincterotomy (LA , GA)
• Healing in 90 to 95 %,minor incontinence 10
% Recurrence is 10 %
 Rectal prolapse
Predisposing factors
Infants
• Absent sacral curve
• Reduced anal tone
Children
• Diarrhea
• Severe whooping cough
• Decreased ischiorectal fat due to malnutrition
Adults
• Torn perineum
• Straining from urethral stricture
Elderly
• Atony of sphincter
 Rectal prolapse
Types
• Partial
• Complete
Partial rectal prolapse
• The mucus membrane & submucosa of the
rectum protrude outside the anus for ~1-4 cm
• Age :the extremes of age
 Rectal Prolapse
Complete rectal prolapse
• All layers of rectal wall protrude through the
anus > 4 cm
Epidemiology
• Common in elderly
• M:F = 1:6
 Rectal Prolapse
Clinical feature
• Prolapsed mass reduced by itself or manually
• Mucus discharge ,bleeding and anorectal pain
• Irreducible mass
• Associated with prolapse of uterus or past
gynecologic operations
• Patulous anal sphincter
• Incontinence in 50 % of cases
 Rectal Prolapse
Investigation
• Colonoscopy & barium enema
• Manometry & electromyography
 Rectal prolapse
Treatment
Infants & children
• Digital reposition
• Submucus injection with phenol 5 %
• Thiersch’s operation Partial
Adults prolapse
• Submucus injection
• Excision of prolapsed mucosa
 Rectal prolapse
Treatment
• Surgery is a must
• Two approaches Complete
⮚ Perineal prolapse
⮚ Abdominal
Thanks

Any Question?