L16: Benign Anorectal Conditions Flashcards
Examples of Benign Anorectal Conditions
Anal Canal anatomy
Def of Haemorrhoids (Piles)
Engorged displaced anal cushions.
Anal cushion showing Treitz’s muscle contribution to anal pressure and maintain continence.
…
Etiology of Haemorrhoids (Piles)
Primary piles
▪ Hereditary congenital weakness of vein walls.
▪ Disruption of Treitz muscles due to chronic staining at stool.
Secondary piles
▪ Pregnancy.
▪ Cancer rectum.
▪ Obstruction of venous return from anal cushions.
(It has no relation to portal hypertension)
CP of Haemorrhoids
Symptoms of Haemorrhoids
▪ Bright red bleeding at the end of defecation.
▪ Prolapse
▪ Mucoid discharge and pruritus
Bleeding in Haemorrhoids
Bright red bleeding at the end of
defecation.
Do Haemorrhoids Cause Pain?
Uncomplicated piles are painless
Do Haemorrhoids Cause Anemia?
Piles rarely cause anemia
Grades of Haemorrhoids
Complications of Haemorrhoids
Strangulation in Haemorrhoids
Piles are painful, purple, tender,
and tense.
Thrombosis in Haemorrhoids
(after 12 h): Pain decreases, becomes solid, and marked edema of the anal margin develops.
Gangrene in Haemorrhoids
Rarely complicated by severe anorectal sepsis and portal pyemia
Thrombosed external piles
Pain in Thrombosed external piles
Sudden severe pain that peaks within 48 hours.
Characters of Thrombosed external piles
Purple black, tender, and tense perianal swelling.
TTT of Haemorrhoids (Piles)
TTT of Grade I & II Haemorrhoids (Piles)
Medical treatment for grade I & II and secondary piles.
TTT of Garde II & III Haemorrhoids (Piles)
Rubber band ligation (RBL) for grade II & III piles.
TTT of Grade III & IV Haemorrhoids (Piles)
Excision haemorrhoidectomy (EH) for grade III & IV piles or piles with skin tags
Other Modalities in TTT of Haemorrhoids (Piles)
Medical TTT of Haemorrhoids (Piles)
RBL in TTT of Hemorrhoids
In RBL, The band is applied to ….. above the pile.
mucosa
In RBL, Two piles can be ligated at the same time (repeated after 2 weeks).
..
In RBL, Sloughing occurs within …. days with slight bleeding.
7
RBL is as effective as EH for grade …. piles has higher recurrence (50 % versus 20 %) for grade …. piles
II - III
RBL is Contraindicated in patients with ……
bleeding tendency
Revise Picture of Modalites used in TTT of Hemorrhoids
…
What is the gold standard in TTT of Piles?
Excision haemorroidectomy
RR in Excision haemorroidectomy
Lowest recurrence rate for grade III & IV piles (20%)
Pain & Excision haemorroidectomy
Associated with sever postoperative pain
Methods of Excision haemorroidectomy
Complications of Excision haemorroidectomy
Bleeding, incontinence to flatus, anal stenosis, pain
Algorithm of TTT of Piles
Management of strangulated piles
Managment of Thrombosed external piles
− < 48 h: Evacuation under local anesthesia.
− > 48 h: Hot sitz baths and stool softners.
def of Anal Fissure
A longitudinal tear in the anoderm in the anterior or posterior midline.
Types of Anal Fissure
Can be acute or chronic (recurrent or persisting for > 6 ws).
Etiology of Anal Fissure
Causes of Idiopathic anal fissure
▪ Forceful dilatation of the anal canal by a firm stool.
▪ It persists due to pain induced spasm of the internal sphincter leading to mucosal ischemia.
Causes of Specific anal fissure
perianal Crohn’s disease and sexually transmitted diseases.
CP of Anal fissure
Incidence of Anal fissure
- It is common in young adult females.
- It is not rare in infants and children.
Pain in Anal fissure
Pain: Sharp and lasts for few hours.
Examination of Anal fissure shows ….
Characters of Specific anal fissure
▪ Ulcers with little pain, or non-healing.
▪ Ulcers off the midline or not related to the dentate line.
TTT of anal fissure
Aim in TTT of anal fissure
Complete relaxation of the internal
sphincter.
Medical TTT of anal fissure
Botox in TTT of anal fissure
temporary paralysis for internal
sphincter to allow healing.
Partial internal sphincterotomy in TTT of Anal Fissure
When medical treatment fails or for recurrent or chronic anal fissure.
def of Chronic anal fissure
persistent for > 1 month or with sentinel pile
Complications of Partial internal sphincterotomy
Can cause permanent incontinence to flatus in 5 % of cases.
Algorithm in TTT of Anal Fissure
Types of Rectal Prolapse
1- Internal rectal prolapse.
2- External (complete) rectal prolapse.
Def of Internal rectal prolapse
- Prolapse of the proximal rectum into rectal lumen during straining at defecation.
Grades of rectal prolapse
CP of Internal rectal prolapse
Investigations for Internal rectal prolapse
TTT of Internal rectal prolapse
- Stapled transanal rectal resection (STARR).
- Ventral mesh rectopexy
Def of Complete rectal prolapse
- Protrusion of all layers of the rectal wall outside the
anus. - Considered the end stage of rectal intussusception or internal rectal prolapse.
Pathological Anatomy of Complete rectal prolapse
− It is more common in old females usually associated with uterine prolapse.
− In the Middle East it is more common in young males.
Symptoms of Complete rectal prolapse
Findings of Complete rectal prolapse on Examination
Compare between Partial & Complete Rectal Prolapse in terms of
- Incidence
- Age
- Layers
- Length
- Muscosa
- Thickness
- Contents
- Continence
TTT of Rectal Prolaspse
TTT of Rectal Prolaspse
- Abdominal Procedure
a) Posterior rectopexy:
1) Well’ operation.
2) Repstein operation.
3) Suture rectopexy.
4) Resection rectopexy.
b) Ventral mesh rectopexy
TTT of Rectal Prolaspse
- Perineal Procedure
a) Delorme`s operation.
b) Altemeier’s operation (perineal rectosigmoidectomy).
c) Stapled transanal rectal resection (STARR).
d) Thiersch’s operation.
Adv & Disadv of Abdominal procedures for rectal prolapse
Less recurrence but risk of injury to pelvic nerves and higher postoperative complication.
Adv & Disadv of Perineal procedures for rectal prolapse
More safe but have more recurrence.
What are other perineal procedures for rectal prolapse?
− STARR: Perineal proctectomy using staplers.
− Thiersch’s operation: Purse string narrowing of the anus around the index finger.
Procedure of Posterior rectopexy
- Complete mobilization of the rectum.
- Rectum fixed to the sacrum by a mesh (e.g. Well s operation & Repstein s operation) or sutures (suture rectopexy).
- Sigmoid resection can be added to suture rectopexy (resection rectopexy).
SE of Posterior rectopexy
▪ Recurrence: 5%
▪ Constipation: 70%
▪ Incontinence: improves in 70% of cases after several methos.
Procedure of Ventral mesh rectopexy
- Anterior dissection of the rectum till the pelvic floor.
- A mesh strip is fixed to the rectum and sacral promontory.
Advantages of Ventral mesh rectopexy
Avoids lateral dissection of the rectum so there is no postoperative constipation
Procedure of Delorme`s operation
- Excision of the mucosa covering the prolapsed part.
- Longitudinal plication of the muscular rectal wall.
- Mucosa to mucosa sutures.
Disadvantages of Delorme`s operation
Recurrence: At least 20%.
▪ Safe operation.
▪ Constipation and incontinence improve.
Procedure of Altemeier`s operation
- Full thickness excision of the prolapsed rectum.
- Coloanal anastomosis.
SE of Altemeier`s operation
▪ Recurrence: 10%.
▪ Mortality: < 5%.
▪ Patient complains of low anterior resection syndrome. (Frequency − Urgency)
The gold standard was ……
was posterior rectopexy then ventral mesh rectopexy
Resection rectopexy: when there is associated slow transit
..
Perineal procedures reserved for elderly patients with comorbidities, young males, and children.
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STARR: in small rectal prolapse or internal rectal prolapse.
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Thiersch’s operation: For frail patients.
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Postanal repair for patients with incontinence.
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Done
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