JC62 (Surgery) - Anorectal diseases Flashcards
Common S/S of anorectal diseases
- Bleeding (fresh)
- Anal pain
- Discharge (bloody or purulent)
- Prolapse
- Peranal mass
- Pruritis ani
- Incontinence
Outline P/E for anorectal diseases
General exam
Abdominal exam
Perianal exam
Digital rectal exam
Proctoscopy
Investigations for anorectal diseases
- Imaging
- Physiological tests
Imaging:
- Rigid sigmoidoscopy
- Flexible endoscopy
- Transrectal ultrasound
- MRI: complicated abscesses/ fistulas
- Others (old, superceded): Defecography, Fistulogram
Physiological: constipation and incontinence
- Anorectal manometry
- Electromyogram
- Pudendal nerve latency test
Indications for transrectal ultrasound
Staging rectal cancer
Assess sphincter muscles in fecal incontinence
Assess complex fistula
Hemorrhoids
- Definition
- physiological function
Cushions of vascular tissue at anal canal
Physiological functions:
- Continence
- Protect sphincters/ anus from trauma of defecation
Differentiate external and internal hemorrhoids
- Anatomical division
- Pain sensation or not
- Histological differences
Internal hemorrhoids
• Above the dentate line with columnar epithelium (i.e. mucosa)
• Receive visceral innervation which is less sensitive to pain and irritation
• Characteristically lie in 3, 7, 11 o’clock positions
•Columnar epithelium (Adenocarcinoma)
External hemorrhoids
• Below the dentate line with squamous epithelium (i.e. skin)
• Surrounds the anal verge and are not true hemorrhoids
• Receive somatic innervation which is more sensitive to pain and irritation
• Stratified squamous epithelium (SCC)
Compare the epithelium, nerve supply, venous drainage and LN drainage of upper and lower anal canal
Hemorroids
Causes/ etiologies
- Risk factors
Low fibre diet
Family history of hemorrhoids
2. Increased intra-abdominal pressure Pregnancy Constipation, straining Chronic cough Obesity
Classify internal hemorrhoid severity
Four degrees of internal hemorrhoids
1st degree: Bleeding only without prolapse
2nd degree: Prolapse at defecation but reduce spontaneously afterwards
3rd degree: Prolapse and have to be manually reduced
4th degree: Permanently prolapsed, Cannot reduce
S/S of hemorrhoids
Irritation or pruritus
Bright-red painless bleeding (ALWAYS exclude other possible sources of PR bleeding)
Mucous discharge
Prolapsed mass
Pain (from complications like thrombosis, prolapse)
Treatment plans for different severities of hemorrhoids
Non-surgical/ non-operative treatment of haemorrhoids
Diet modification: High fiber diet
Sitz bath: relax sphincter muscles and reduce spasm, pruritis, inflammation
For significant haemorrhoids with prolapse
Ointment and suppositories
- Analgesic cream: mixed lidocaine/ hydrocortisone
- Hydrocortisone suppositories: shrink hemorrhoids
- Venoactive agents: Phlebotonics e.g. Daflon to control bleeding
Laxatives/ Stool softeners
- Osmotic laxative e.g. Lactulose
- Bulk laxative e.g. Methycellulose
- Stimulant laxative e.g. Senna/ Bisacodyl
Operative/ Surgical treatment options for haemorrhoids
Office procedures
- Rubber band ligation
- Sclerotherapy
- Infra-red coagulation
In-patient:
- Surgical hemorrhoidectomy
- Stapled haemorrhoidopexy
- Transanal hemorrhoidal artery devascularization
Indications for surgical hemorrhoidectomy
Complications
Indications:
- Severe hemorrhoids: 3rd or 4th degree
- Mixed internal and external haemorrhoids
- Failure of other treatments
- Patient preference
Complications:
- Bleeding, pain, infection
- Urine retention
- Fecal impaction
- Anal tags and anal stenosis
- Incontinence
Rubber band ligation of hemorrhoids
- Benefits
- Indications
- C/I
- Complications
Benefits: Most commonly performed since it is inexpensive, easy to perform and rarely causes serious complications
Indication: Only for internal hemorrhoids, grade I,II and III
C/I:
NOT recommended for Grade IV hemorrhoids
Contraindicated in patients with coagulopathies or patients with cirrhosis and portal hypertension due to the risk of significant delayed hemorrhage
Complications o Pain (most frequent occurring in 8%) o Delayed hemorrhage o Localized infection/ Sepsis o Urinary retention o Hemorrhoidal thrombosis
Injection sclerotherapy for haemorrhoids
- Procedure
- Indication
- Procedure: Injection of sclerosants such as phenol (5%) in vegetable oil which causes an intense inflammatory reaction destroying redundant submucosal tissue associated with hemorrhoidal prolapse
- Indication:
coagulopathies, on antiplatelets or anticoagulants, immunocompromised or with portal hypertension (opposite to rubber band ligation)
Stapled hemorrhoidopexy
- Procedure
- Advantages
- Disadvantages
Procedure:
stapling device to remove a ring of rectal mucosa and mucosa with the creation of a mucosal anastomosis above the dentate line
hemorrhoidal tissues are pulled back into anal canal from prolapsed position and the blood supply to hemorrhoids are interrupted
Advantages over hemorrhoidectomy
o Less pain and analgesic, quicker recovery and shorter hospital stay
o Less post-operative bleeding and wound complications
o Higher patient’s satisfaction
Disadvantages over hemorrhoidectomy
o Higher recurrence rate
o Serious complications can occur including rectal perforation, rectovaginal fistula and pelvic sepsis
Transanal hemorrhoidal artery vascularization
Procedure
- Small ultrasound probe insert into anus to locate vessels of hemorrhoids
- Each blood vessel stitched close to block bloodflow to hemorrhoids
- Optional hemorrhoidectomy after
Complications of untreated hemorrhoids
Complications of hemorrhoids Strangulation and thrombosis Gangrene Ulceration Fibrosis Portal pyemia
Fissure-in-ano
- Definition
- Typical location
- Histological changes in chronic fissure
- Definition: Split in anoderm at the dentate line
- Typical location: 90% at posterior midline
- Histological changes in chronic fissure: Sentinel pile, hypertrophic papilla, visualize internal sphincter muscles at base of fissure
Causes/ Etiologies of Fissure- in- ano
Primary and secondary causes
1. Primary causes Local trauma to anal canal • Passage of hard stools • Prolonged diarrhea • Vaginal delivery • Anal sex
- Secondary causes
Inflammatory bowel disease
• Crohn’s disease
• Ulcerative colitis
Granulomatous disease
• Extrapulmonary TB
• Sarcoidosis
Malignancy
• Squamous cell anal cancer
• Leukemia
Sexually-transmitted diseases
• HIV infection
• Syphilis
• Chlamydia
Pathogenesis of anal fissures
Stretching of anal mucosa beyond its normal capacity
• Repeated injury leads to spams of the exposed internal sphincter muscle beneath the tear
• Spasm pulls the edges of fissure apart which impairs healing of wound
Ischemia secondary to reduced perfusion
• Anoderm at posterior midline has less blood flow than other quadrants in anal canal
• Increased anal pressure leads to reduced rate of perfusion
Fissure-in-ano
S/S
Typical and atypical features
Signs and symptoms:
1. Painful defecation
• Tearing pain with passage of bowel movements
2. Bright rectal bleeding
• Limited to a small amount on toilet paper or surface of stool
3. Perianal pruritus or skin irritation
Typical features:
• Single posterior or anterior fissure without evidence of Crohn’s disease
Atypical features
• Multiple, recurring, non-healing, deep or wide, painless and at off-midline locations
• Suggests secondary causes of anal fissures
Ddx fissure-in-ano
Perianal ulcers or sores
Anorectal fistula
Solitary rectal ulcer syndrome
Physical examination technique for anorectal fissure
How to differentiate acute from chronic fissure
Most common location of primary anal fissure is posterior anal midline
Spread buttock to reveal fissure, DO NOT PERFORM RECTAL EXAM OR PROCTOSCOPY
Acute fissure (Pathognomonic feature = Superficial tear)
o Superficial tear
o Fresh laceration resembling a paper cut
Chronic fissure (Pathognomonic feature = Hypertrophied with skin tags or papillae)
o Raised edges exposing white horizontally oriented fibers of the internal anal sphincter muscle fibers at the base of fissure
o Hypertrophied anal papillae at the proximal end of fissure
o Skin tags (sentinel pile) at the distal end of fissure
Non-operative/ Medical treatment options for anal fissure
- Bulk agents and Stool softeners
- Warm Sitz Bath
- Topical anesthetics: Lidocaine jelly
- Reduce internal sphincter pressure: Topical vasodilators
• Topical nifedipine ointment
• Topical nitroglycerin ointment
Surgical treatment options for fissure-in-ano
Indicated in patients who fail 8 weeks of initial medical treatment
Botulinum toxin type A injection
Lateral internal sphincterotomy
Anorectal abscess
Etiologies
Cryptoglandular infection*
• Infection of the anal glands
Other infections • Inflammatory bowel disease • Tuberculosis • Actinomycosis • Foreign body - Surgical
Malignancies
Describe the progression of cryptoglandular infection into systemic infection
Acute phase manifestation of a collection of purulent material that arises from glandular crypts in anus or rectum
• Anorectal fistula is the chronic phase of suppuration in this perirectal process
Traverse distally in intersphincteric groove into perianal skin
Can expand into adjacent tissues including ischiorectal and supralevator space or even progress into generalized systemic infection
Anorectal abscess
4 different sites
Different sites of anorectal abscess Perianal region (20%) Intersphincteric region (18%) Ischiorectal region (60%)**** Supralevator region (2%)
Anorectal abscess
Pathogenesis
S/S
Treatment
Pathogenesis of an anal abscess
Originates from an infected anal crypt gland which penetrate the internal sphincter and end in the intersphincteric plane
Obstruction of anal crypt gland with inspissated debris permits bacterial growth and abscess formation
Signs and symptoms Pain in anal or rectal area • Constant pain • Not necessarily associated with a bowel movement • Associated with symptoms including fever and malaise Purulent discharge Constipation Urinary difficulties
Tx:
Incision and drainage***
Antibiotics has MINIMAL role
• Except in patients with cellulitis, valvular heart disease, prosthetic heart valves and immunosuppression
Differential dx of anorectal abscess
Anorectal fistula
Internal hemorrhoid
Presacral epidermoid cyst
Fistula-in-ano
Definition
4 classifications
Fistula is a communication between 2 epithelial surfaces
Anorectal fistula is the chronic manifestation of the acute perirectal process that forms an anal abscess
• When the abscess ruptures or is drained an epithelialized track can form that connects the abscess in the anus or rectum with the perirectal skin
Classification:
- Intersphincteric
- Transphincteric
- Extrasphincteric
- Suprasphincteric
Classification of anorectal fistulas
Pathogenesis
Majority of anorectal fistula originate from an infected anal crypt gland
• Glands penetrate the internal sphincter and end in intersphincteric plane
Anorectal fistula is the connection between two epithelial structures
• Connects the anal abscess from the infected anal crypt glands to the perirectal skin
Anorectal fistula
Differentiate simple and complex fistula
Simple fistula
• Minimal involvement of external sphincter
• Park’s classification Type 1 (intersphincteric)
• Park’s classification Type 2 (transsphincteric) involving < 30% of anal sphincter complex
Complex fistula
• Any fistula involving more than 30% of external sphincter
• Park’s classification Type 3 (suprasphincteric)
• Park’s classification Type 4 (extrasphincteric)
• Fistula with multiple tracts
• Recurrent fistula
• Fistula related to inflammatory bowel disease (IBD), infections, local radiation
Causes/ etiologies of anorectal fistula
Ddx
Anorectal abscesses (most common >90%) • Often evolves from a spontaneously draining anorectal abscess originating from the crypts of Morgagni (cryptoglandular infection) which are located between two layers of anal sphincter
Other causes:
Crohn’s disease, Lymphogranuloma venereum (Chlamydia trachomatis), Radiation proctitis, Rectal foreign bodies, Actinomycosis
Ddx:
Anal abscess
Anal fissure
Anal ulcers or sores
Anorectal fistula
S/S
Painful defecation
• Intermittent rectal pain particularly during defecation but also with sitting and activity
Bleeding
Swelling
Purulent drainage - lowers pain
• Intermittent and malodorous perianal drainage
Perianal pruritus
Anorectal fistula
Investigations
Indication for imaging
Internal and external opening of fistula tract need to be identified
Anorectal examination
Anoscopy or sigmoidoscopy
Radiological tests
Examination under anesthesia (EUA) with Fistula Probe
Imaging modalities:
• Endosonography (EUS)
• CT/ MRI anal canal
• Fistulography
MRI for: complicated high fistula, recurrent fistula, poor anatomy
Anorectal fistula
Surgical treatment options
Alternative/ advanced treatment options
Simple low fistula - Fistulotomy/ Fistulectomy
Complicated high fistula/ transphincteric fistula with muscle involvement:
- Setons: Cutting (snug) seton, Draining seton
- Endorectal advancement flap: Closing off the internal opening of fistula by a mobilized flap
- Anal fistula plug: ameliorate postoperative incontinence
- Ligation of intersphincteric fistula tract (LIFT): Secure closure of internal opening and removal of infected cryptoglandular tissues
Others: Video-assisted anal fistula treatment (VAAFT) - FiLaC (Fistula tract laser closure) - Permacol paste injection - Stem cell treatment
Pruritis ani
- S/S
- Etiologies
- Tx
S/S:
Itchiness in peri-anal region, lead to excoriations and secondary infections
Etiologies:
- Idiopathic
- Personal hygiene
- Diet
- Dermatological conditions
- Infections
- Psychogenic
- Diarrhea
- Systemic diseases, drugs
Tx: Treat underlying cause Reassurance Skin care: keep perianal skin dry, avoid soap, avoid prolonged topical steroids Change diet
Rectal prolapse
Definition
Cause
Differentiate complete and partial prolapse
Rectal prolapse is a pelvic floor disorder. Full thickness protrusion of rectum through anal sphincters
Failure of pelvic floor muscles/ levator ani (puborectalis + pubococcygeus + iliococcygeus muscles)
Extent of rectal prolapse
• Complete rectal prolapse refers to protrusion of all layers of rectum through the anus
• Partial rectal prolapse refers to protrusion of the mucosa only
Complications of rectal prolapse
Rectral intussusception
Loss of rectal fixation
Redundant sigmoid
Levator ani diastasis
Patulous anal sphincter
Pudendal neuropathy
Rectal prolapse
Etiologies
Neurological disorders
Parity
Chronic Constipation/ straining/ diarrhea
Childhood factors: Cystic fibrosis, Whooping cough, Developmental abnormalities, Malnutrition
Outline risk factors of rectal prolapse
Demographics
• Female age > 40
Medical history • Chronic straining • Chronic constipation • Chronic diarrhea • Pelvic floor dysfunction • Pelvic floor anatomic defects: Rectocele, Cystocele, Enterocele, Deep cul-de-sac • Dementia • Stroke
Surgical history
• Prior pelvic surgery
Obstetrics and gynaecological history
• Multiparity
• Vaginal delivery
Rectal prolapse
S/S
Fecal Incontinence
Constipation
Protrusion
Pain, Bleeding and mucus/stool discharge
Tenesmus/ Rectal pressure
Rectal prolapse
Treatment options for abdominal and perineal repair
Abdominal repair: Rectal fixation (suture/ mesh) Sigmoid resection Proctectomy Combination rectal fixation and sigmoid resection Laparoscopic Ventral Mesh Rectopexy
Perineal repair:
Full thickness resection
Mucosal resection with muscular reefing
Anal encirclement
Epidermoid carcinoma of anal canal
Risk factors
S/S
Treatment
RF:
Anal intercourse
Sexually transmitted diseases
HPV infection
S/S:
Bleeding, pain and anal mass
Tx:
Chemoradiation
Abdominal perineal resection (for residual or recurrent disease)
Anal melanoma
- S/S
- Prognosis
- Tx methods
S/S: Bleeding, pain, mass
Local invasive and early metastatic presentation
Prognosis: 6-20% post curative Tx
Tx:
Abdominal perineal resection/ wide local excision, Immunotherapy
List 3 anal margin cancers
SCC
BCC
Kaposis sarcoma
