Perianal Condtions 01-06-2010 Dr. Nazeem

8/13/2019 Perianal Condtions 01-06-2010 Dr. Nazeem

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PERI N LCONDITIONSINFECTIVE

INFLAMMATORY

COMPLICATIONS OF ABOVEOTHERS

TUMOURS


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H EMORRHOIDSDEFINATION

Enlarged, dilated veins in relation toanus.


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May be external or internal to the anal orifice.

When both varieties present they are known asintero- external haemorrhoids.

External haemorrhoid arise from the skincovered lower 3rd of the anal canal.

Internal haemorrhoid arise from the veins of

the haemorrhoidal plexus of veins in the upper3rd of the anal canal covered by mucusmembrane.


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ETIOLOGY Hereditory:

seen in some members of the family,

so there must be some predisposingfactors such as congenital weakness of

the walls of the veins or abnormal large

arterial supply to the rectal plexus.Varicose veins and haemorrhoids are

often seen together.


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Local obstruction: low rectal tumour causingcompression or thrombosis of superior rectalveins and thus leading to haemorrhoids.

Increased Intra-abdominal Pressure: Inpregnancy variety of factors combine toproduce this condition.

1) Pregnant uterus compressing superior

rectal veins,2) Progesterone having relaxant effect on thesmooth muscles of the veins

3) Increase pelvic circulatory volume.


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Straining on micturation: due to stricture

of urethra or enlarged prostate.

Chronic constipation.


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Pathology Haemorrhoids occurs at three main areas,

situated at 3, 7and 11 clock position. In

between these, there may be secondaryhaemorrhoids.

Each principle haemorrhoid can be divided into

Pedicle: situated at the ano-rectal ring,

branches of the superior rectal artery mayenter it.


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Internal haemorrhoid: commences just

below the ano-rectal ring, covered by

mucus membrane Associated Ext: haemorrhoids- between

dentate line and anal margin


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DEGREE 1STDegree haemorrhoid: haemorrhoids that

bleeds but do not prolapse.

2ndDegree haemorrhoid: haemorrhoids thatprolapse through the external sphincter during

defecation but retract spontaneously or to be

replaced manually and stay reduced.

3rdDegree haemorrhoid. Permanently

prolapsed outside the anal canal


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Clinical Features Bleeding: Principal and earliest symptom.

At 1stslight and bright red and occurs

during defecation. Discharge: mucus discharge followed by

defecation.

Pain: is absent unless complicationoccurs

Anaemia: iron deficiency type.


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INVESTIG TIONSDigital examination:

Cannot be felt unless thrombosed

Proctoscopy:Proctoscope passed to full extent

and then slowly withdrawn. Haemorrhoid ifpresent bulge into the lumen of proctoscope.

Sigmoidoscopy:Should be done as a precautionary

in every case


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COMPLIC TIONS Profuse haemorrhage

Strangulation

Thrombosis

Ulceration

Gangrene

Fibrosis

Portal pyaemia


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TRE TMENT Conservative

is recommended when haemorrhoidsare the symptoms of some otherconditions or disease except whencarcinoma is present. The bowls areregulated by some sort of laxatives.

Injection Treatment:


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TRE TMENTideal for 1stdegree and early 2nd

degree haemorrhoids.

Rubber Band Ligation: an outpatientprocedure. Can be advised for both 2ndand 3rddegree piles.

Cryosurgery: cryo-probe (liquid nitrogen

-196 c) applied to mucosa over thedilated venous plexus, as outpatientprocedure. The procedure cause severemucous discharge, thus limiting its use.


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TRE TMENTPhotocoagulation:

Infra-red coagulation to thosehaemorrhoids that do not prolapse,effective and painless method oftreatment.


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TRE TMENTLords procedure: internal haemorrhoids

caused by constricting bands in the analcanal causing difficulty in defecation,

leading to increased straining at the stoolwhich increases venous pressure in thehemorroidal plexus of vein. Four fingeranal dilatation under G.A is performed


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OPER TIVE TRE TMENT INDICATIONS:

a) unsuitable for banding and injection

therapyb) 3rddegree haemorrhoids

c) Failure of conservative and non-

operative treatment

4) Intero- external haemorrhoid


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H EMORRHOIDECTOMY There are different methods of performing

haemorrhoidectomy but ligation and excisiontechnique of Milligan and Morgan is widely

used. Complications:

Immediate

a) Pain

b) Retention of urinec) Reactionary haemorrhage

d) secondary haemorrhage. 7thor 8thday.


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Delayed:

a) Incontinence- loss of sphincter control

b) Stricture formation- removal of toomuch skin at the time of operation.

c) Anal fissure- sub mucus abscess may

occur.

d) Residual skin tag.


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ST PLEH EMORROIDECTOMY New techinque


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Tract lined by granulation tissue, theinternal opening of which lies in the

anal canal or in the lower rectum andthe external opening on the skinaround the anus.

Commonly, there is one internal

opening but there may be manyexternal openings.

N L FISTUL E


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ETIOLOGY Pyogenic Abscess:

commonest cause of fistula.

Infection in the anal glands lying between theexternal and internal sphincter in the inter-

sphincteric plane that tracts inferiorly and

present inferiorly at the anal verge as perianal

abscess or penetrate the external sphincter toform ischio- rectal abscess. This abscess at

some point penetrates the mucosa and skin to

form fistula.


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Secondary to other conditions

a) ulcerative colitis

b) Crohns disease

c) Carcinoma rectum and anal canal


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Types of Anal Fistulae

Divided into two types according to

internal opening above or below the ano-

rectal ring levator ani

1) Low anal fistula: below the ano-rectal

ring.

2) High Anal fistula: above the ano-rectal

ring.


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An elongated ulcer or breach in the squamousepithelium of the lower anal canal. May be

Acute Anal Fissure-

Sudden onset and deep tear through the

skin of the anal margin extending into the anal canal,little inflammatory induration or oedema andaccompanied by spasm of anal sphincter

Chronic Anal Fissure-

Inflammed indurated margin and the

base consisting of either scar tissue or the lower borderof internal sphincter muscle.

N L FISSURE

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Perianal Condtions 01-06-2010 Dr. Nazeem