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ANORECTAL DISEASES
Bernard M. Jaffe, MDProfessor of Surgery, Emeritus
Tulane University School of Medicine
ANAL CANAL• Borders- Coccyx• Ischiorectal Fascia Bilaterally• Female- Perineal Body; Male-
Urethra• Disorders Common and Generally Benign• BUT • Painful and Disabling• Divided Into Upper and Lower Segments
UPPER VS. LOWER UPPER• Above Dentate Line
(Marked by Anal
Valves)• Pleated, Folded Mucosa• 12-14 Columns of
Morgagni• Anal Crypts Between
Columns• Cuboidal Epithelium
LOWER
• Below Dentate Line
• Smooth Mucosa• Absent
• Absent• Squamous Epithelium
ANAL SKIN• Continuous with Anal Canal• Contains Apocrine Glands• Site of Hydradenitis Suppurativa• Pain Receptors (Not Stretch)• Lesions Drain to Inguinal Nodes
VASCULAR• Arterial Supply• Bilateral, Duplicated• Middle and Inferior Hemorrhoidal
Arteries Off Internal Iliac• Venous Drainage• Bilateral, Duplicated• Internal Iliac Veins to Inferior Vena
Cava
ANAL MUSCULATURE• One Tubular Structure Inside Another• Inner- Continuation of Rectal Circular Layer• Extends 1.5cm Beyond Dentate Line• Involuntary • Forms Internal Sphincter• Outer- Continuous Sheet of Striated Muscle
of Pelvic Floor• External Sphincter• Voluntary Control
HEMORRHOIDS• Abnormal Anal Cushions• Cushions Contain Blood Vessels,
Smooth Muscle, Elastic and Connective Tissue
• Left Lateral, Right Anterior, Right Posterior Positions
• Unknown Causes, Includes Straining• Common During Pregnancy
EXTERNAL HEMORRHOIDS• Covered by Anoderm• Distal to Dentate Line• Swell, Causing Discomfort, Difficult
Hygiene• Sever Pain Only with Thrombosis
INTERNAL HEMORROIDS• Cause Painless Bright Red Bleeding• Prolapse with Defecation• Mucus Secretion• Itching • Pain is Rare (No Mucosal
Pain Receptors)
HEMORRHOID GRADES• 1◦ Bleeding Diet• 2◦ Prolapse, Bleeding Rubber Band Ligation• 3◦ Prolapse with Hemorrhoidectomy or• Digital Reduction, or Rubber Band
Bleeding Ligation• 4.◦ Strangulation Urgent
Hemorrhoidectomy
OFFICE TREATMENT• Dietary Management (for All Grades)• Fiber Supplements• Local Hygiene• Avoidance of Straining• Medication to Soften Stool• More Extensive- Rubber Band
Ligation
HEMORRHOIDECTOMY• Indications• Failure of Conservative Measures• Prolapse Requiring Manual Reduction• Strangulation• Ulceration• Commonest Complications• Bleeding• Urinary Retention
ANAL FISSURES• Almost Always Directly Posterior• If Not- STD’s, Crohn’s, Hydradenitis• Associated Findings-• Sentinal (External) Pile• Enlarged Anal Papilla• Causes Pain, Mild Bleeding• Responds to Sitz Baths, Bulking Agents
ABCESSES• Originate in Intersphincteric Plane • Usually From Anal Gland• If Progress Downward to Skin Causes
Perineal Abcess• If Progresses to Other Sites• More Complicated• Harder to Treat
OTHER SITES OF ABCESS• Intermuscular- Vertical Tracking• Supralevator- Vertical Tracking• Tough to Diagnose• Ischiorectal- Horizontal Tracking• Horseshoe- Circumferential Tracking
ABCESS TREATMENT• Drainage is Critical• Superficial Abcess- Office Drainage• Attempt to Localize Site of Origin
Within the Anal Lumen • Needle Localization or CT Imaging
May Be Necessary to Localize More Complex Abcesses
OPERATIVE DRAINAGE• OR Required for • Complex (Horeshoe Abcess)• High (Supralevator) Abcess• Immunocompromised
Patients• Patients With Systemic
Symptoms
FISTULA-IN-ANO• Complicates Anorectal Sepsis in 25% • Originates in Dentate Line in Anal Canal• Presents With Purulent Peri-Anal Drainage• Punctate Indurated Papule
With Opening• Inner Opening Identified by Probing at
Dentate Line from Drainage Site• May Have Multiple External Drainage
Openings
TYPES OF FISTULAS• Type 1- Intersphincteric• Treated by Fistulotomy• Type 2- Transsphincteric• Type 3- Supersphincteric• Type 4- Extrasphincteric• Latter 3 Treated With Seton
SETON• Monofilament Nylon or Rubber Band• Passed Through Fistulous Tract• Causes Fibrosis and Allows Later (8-12
Weeks) Sphincterotomy Without Loss of Continence
• Cutting (Progressively Tightening) Seton Also Acceptable Technique
• Difficult Fistulas- Sliding Flap of Mucosa, Submucosa, and Muscle to Cover Internal Opening
DIFFICULT FISTULAS• Sliding Flap of Mucosa, Submucosa,
and Muscle to Cover Internal Opening• Injection of Fibrin Glue Into Opening• Even With Multiple Openings, There
is Generally Only One Internal Opening
PILONIDAL SINUS• Midline Sacrocoxxygeal Skin• Acute Abcess• Chronic Sinuses • Rarely Confused With Fistula-in-Ano• Related to Hair, Penetration of
Granulation Tissue Into Sinuses• Disease of Young People• Treated by Excision
CONDYLOMA ACCUMINATUM
• Peri-Anal Wart• Caused by Human Papilloma Virus• Associated With AIDS, Anal Intercourse• Difficult to Eradicate- Cautery• Podophyllin• Significant Risk of Epidermoid
Carcinoma
HYDRADENITIS SUPPURATIVA • Chronic Inflammatory Process• Occurs in Peri-Anal Area and Other Hair-
Bearing Areas • Most Likely Theory- Debris Occludes
Apocrine Gland →Purulence → Rupture→ Subqu Infection
• Organisms- Strep milleri, Staph aureus, epidermitis, and hominis
TREATMENT• Antibiotics• Drainage, Debridement• Fistulotomy (Distal to Dentate Line)• Wide Local Excision With Skin Graft• Difficult to Eradicate• 30% Recurrence Rate• Association With Squamous
Carcinoma
CROHN’S DISEASE• Anorectal Disease in 20%• Jeopardizes Continence 2◦ Inflammation• Causes Fissures, Abcesses, Fistulas• Fistulas Proximal to Dentate Line• Can Be First Manifestation of Disease• Symptoms- Pain, Bleeding, Soilage, Poor
Continence
TREATMENT• CONSERVATIVE MANAGEMENT• Treat Ileal Crohn’s Dsiease• Sitz Baths, Stool Softeners, Analgesics• Steroids, 6 M-P, Azothiaprine,
Cyclosporine• Avoid Fistulotomy- If Needed, Use Seton• Difficult to Manage- Non-Resposive• Often Extensive
EPIDERMOID CARCINOMA• Anal mass With Bleeding, Pruritis• Epidermoid, Basaloid, Cloacogenic,
Mucoepidermoid Types • <3cm in Size• 25% Superficial or in Situ• 71% Deep Penetration, 25%Node
Positive, 6% Distal Metastases• Increased Frequency in AIDS•
TREATMENT• Superficial Lesions <2cm- Local Excision• Remainder- Nigro Protocol (Radiation, 5-FU,
Mitomycin)• Almost All Respond and
TREATMENT• Superficial Lesions <2cm- Local Excision• Remainder- Nigro Protocol (Radiation, 5-
FU, Mitomycin)• Almost All Respond and Disappear• APR for Failure of Nigro Protocol• Contraindication to RT, Chemo• Deep Invasion• Aggressive Lesion