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ANAL CANAL Dr. Tanuj Paul Bhatia
ANATOMY
Most distal portion of the alimentary canal.
Extends for a distance of about 3 cm from the anorectal ring to the hairy skin of the anal verge.
Anus provides continence for flatus and faeces.
White line
Dentate line
Anal crypts and columns
Anal gland
Internal hem. plexus
Int. sphincter
External sphincter
NERVE SUPPLY
Below the dentate line, cutaneous sensations conveyed by afferent fibers in the inferior rectal nerves.
Above the dentate line : parasympathetic fibres
BLOOD SUPPLY
Arterial supply : The middle rectal arteries arise from the internal
iliac arteries. The inferior rectal arteries, branches from the
internal pudendal arteries. Venous drainage :
Above dentate line : Int. hem. plexus sup rectal vein Inf. Mesenteric vein
Below dentate line : Ext. hem. Plexus Middle rectal vein Int. iliac vein OR Inf. Rectal vein pudendal vein Int. iliac vein
SPHINCTER COMPLEX
External sphincter Extension of levator ani around anorectum Voluntary sphincter Supplied by pudendal nerver 3 compnents :
Subcutaneous Superficial Deep
INTERNAL SPHINCTER
Involuntary sphincter Innervated by autonomic nervous
system Formed by extension of rectal
musculature
FORMATION OF ANAL SPHINCTERS
FECAL INCONTINENCE
The principal function of the anal canal is the regulation of defecation and maintenance of continence.
Evaluated by manometry, defecography and electromyography.
CAUSES
MANAGEMENT OF FECAL INCONTINENCE
HEMORRHOIDS
DEGREE OR STAGEWISE CLASSIFICATION 1st degree: bleeding 2nd degree: protrusion but spontaneous
reduction 3rd degree: protrusion that requires
manual reduction 4th degree: irreducible protrusion
External 1st degree
2nd degree
3rd degree
4th degree
TREATMENT OPTIONS
Slerotherapy Rubber band ligation Open hemmorhoidectomy Closed hemmorhoidectomy Stapled hemmorhoidectomy
BAND LIGATION
HEMMORHOIDECTOMY
STAPLED HEMORHOIDECTOMY
DOUGHNUT OF HEM. TISSUE
THROMBOSED EXTERNAL HEMORRHOID
Painful Self curing 5 day
DISEASE
ANAL FISSURE OR FISSURE-IN-ANO
Linear ulcer of lower half of anal canal Posterior fissure is most common Anterior fissures commoner in women
than men Fissure in any other location : suspect
Crohn’s disease Hydradeinitis suppuritiva STDs
POSTERIOR FISSURE-IN-ANO
PATHOGENESIS
passage of large, hard stools, which may be the initiating factor;
inappropriate diet; previous anal surgery; childbirth; and laxative abuse.
SYMPTOMS
With defecation, the ulcer is stretched, causing pain and mild bleeding.
TYPES
Acute fissure in ano Chronic fissure in ano
ACUTE FISSURE IN ANO
Short history Painful No sentinel pile on examination Managed conservatively
CHRONIC FISSURE IN ANO
Recurrent acute fissure Associated with sentinel pile Can be treated conservatively initially
but may require surgery
Sentinel pile : a skin tag formed due to chronic
inflammation and fibrosis
TREATMENT
Non surgical Surgery
AIM: To increase the blood supply to promote healing of the ulcer/fissure
NON SURGICAL TREATMENT
Stool bulking agents Hot tub baths/ Sitz bath Local ointments
Lignocaine Nitroglycerine
Dietary modifications Botox injections
SURGICAL
Sphincterotomy Internal anal sphincter is cut to relieve the
spasm and in turn increase blood supply to the fissure
Midline sphincterotomies cause key hole defects, hence lateral sphincterotomy is done.
2 types : Open Closed
OPEN SPHINCTEROTOMY
CLOSED SPHINCTEROTOMY
ANAL SEPSIS AND FISTULAE
Anorectal abcess – acute form of anal sepsis Fistula in ano – chronic form of the disease
process
Anal fistula : communication between an internal opening in the anal canal and an external opening through which an abscess drained.
ETIOLOGY
Infection of obstructed anal glands : Most common cause
Trauma Foreign body Tuberculosis Actinomycosis Inflamatory bowel disease
CLASSIFICATION
TREATMENT
ANORECTAL ABCESS
PERIANAL ABSCESS
Results frtom suppuration of anal gland or suppuration of a thrombosed external pile
Lies in the region of subcutaneous portion of external sphincter
CLINICAL FEATURES
Severe pain in perianal region Difficulty in sitting Tender smooth and soft swellling in the
perianal region
TREATMENT
Sitz bath Antibiotics Drainage under GA
ISCHIORECTAL ABCESS
Due to extension of intermuscular abcess through external sphincter
Can be blood born as well Fat in fossa more prone for infection as
it is least vascularized Both these fossa are connected one
fossa infection may lead to the infection on other side HORSE SHOE ABCESS
CLINICAL FEATURES
Tender, indurated, brawny swelling in the skin over ischiorectal fossa
Fever Swelling is not well localized so it is
difficult to elicit fluctuation.
TREATMENT
Cruciate incision and drainage Pus for c/s Look for any internal opening (for
presence of internal fistula)
SUBMUCOUS ABCESS
Occurs above the dentate line Can be drained with a sinus forceps
through proctoscope
FISTULA IN ANO
Etiology Cryptoglandular sepsis(most common) Trauma Crohn’s disease Malignancy Radiation
tuberculosis,actinoymycosis
CLINICAL FEATURES
Persistent drainage from internal or external opening
Indurated tract can be palpable on per rectal examination .
External opening easily found but finding the internal opening can be a challenge
GOODSALL’S RULE
‘In general, fitulas with external opening anteriorly connect to internal opening by a short,radial tract.’
Fistulas with external opening posteriorly track in curvilinear fashion to posterior midline.
EXCEPTION : anterior external opening >3cm from anal verge usually follow curved track to posterior midline
CLASSIFICATIONS OF FISTULA IN ANO
1. Park’s classification2. High and low fistula in ano3. Simple and complex fistula in ano
PARK’S CLASSIFICATION
1.Intersphincteri
c
2.Transsphincteri
c
3.Suprasphincter
ic
4.Extrasphincteri
c
SPECIAL INVESTIGATIONS
Trans rectal ultrasound (TRUS)/ Endoanal ultrasound
Fistulogram MRI
SURGICAL MANAGEMENT
Fistulotomy Fistulectomy Setons
FISTULOTOMY
‘Laying open of the fistula tract from its termination to source’
Applied mainly to intersphincteric and transphincteric fistula involving less than 30% of voluntary muscle.
Staged sphincterotomy : part of sphincter is divided and rest tied upon by a seton.
FISTULECTOMY
Coring out of the fistula
SETONS
Latin for Bristle Loose and tight setons : depending
upon the intent of cutting through the muscle.
After tying, these are tightened in intervals of weeks.
‘Cheese wire cutting through ice’ They gradually cut through the muscles
without springing them apart
STAGED FISTULOTOMY
RECENT ADVANCES
1. Advancement flaps2. Tissue glues
PILONIDAL SINUS(JEEP BOTTOM)
Pilus= hair , nidus = nest Of infective origin Occurs in sacral region between the
buttocks Other sites : umbilicus, web spaces of
fingers(in barbers)
PATHOLOGY
Hair penetrate skin causing dermatitis and infection
Persistent infection leads to sinus formation
Primary sinus : midline Secondary sinuses : paramedian
CLINICAL FEATURES
Serosanguinous or purulent discharge Throbbing and persistent pain Sometimes tender swelling in the
midline Tufts of hair may be seen in the
opening of sinus
TREATMENT
Excision of the sinuses Laying open the sinus Z- plasty Rotation flaps Bescom’s operation Karydaki’s operation
ANAL INTRAEPITHELIAL NEOPLASIA
Virally induced dysplasia Risk factors : anoreceptive intercourse
and HIV Usually patients are asymptomatic Based on degree of dysplasia : AIN I,
AIN II, and AIN III AIN II and III have chances of
progressing to invasive carcinoma
CLINICAL FEATURES
30% asymptomatic Suspicious areas are raised, scaly,
white, erythematous, pigented or fissured.
MANAGEMENT
Multiple mapping biopsies Excision followed by colostomy or flaps Topical imiquimod or retinoids have
some effect on progression of diesease.
NON MALIGNANT STRICTURES
1. Spasmodic : due to anal fissure.2. Organic :
1. Postoperative2. Irradiation stricture3. Senile anal stenosis4. Lyphogrnuloma inguinale5. Inflamatory bowel disease6. Endometriosis
CLINICAL FEATURES
Increasing difficulty in defecation ‘Pipe stem’ stools. Stricture can be palpated as annular or
tubular on DRE.
TREATMENT
Dilatation by bougies. Anoplasty. Colostomy. Rectal excision and coloanal
anastomosis.
MALIGNANT TUMORS
Below dentate line : SCC Above dentate line : basaloid,
cloacogenic or transitional carcinomas.
SQUAMOUS CELL CARCINOMA
Risk factors : HPV infection AIN Immunosuppression
CLINICAL FEATURES
Pain Bleeding Pruritus Fecal incontinence as a result of
sphincter invasion. Palpable as indurated, irregular, tender
ulcers.
MANAGEMENT
Primary treatment : chemoradiotherapy CMT(combined modality treatment) 5-FU with mitomycin C or cisplatin
Resection indicated in Small marginal tumors Persistent or recurrent disease followed
by colostomy
THANK YOU