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Perianal Disorders

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Jawad Siddiqi

on 14 August 2012

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Transcript of Perianal Disorders

By Jawad Siddiqi and Abdul Moeed Perianal Disorders Oxford Handbook Of Clinical Medicine Pruritis Ani
Fissure-in-ano
Fistula-in-ano
Anorectal Abscesses
Perianal Haematoma
Pilonidal Sinus
Rectal Prolapse
Anal Ulcers
Skin Tags
Piles/Hemorrhoids
Condylomata Accuminata (Anal Warts)
Anal Cancers COMMON PERIANAL DISORDERS Anatomy of the Anal Canal Pruritis Ani Oxford Handbook Of Clinical Medicine And Browse’s Introduction To The Sign And Symptoms Of Surgical Disease Intractable itching around the anus

Itch occurs if the anal area is moist (conditions that result in mucus secretions) due to:

Fissures, incontinence, poor hygiene, tight pants, chronic diarrhea, contact dermatitis, threadworms, anxiety

Symptom is frequently worse at night perhaps because there are no other sensory distractions PRURITIS ANI Fissure in Ano Oxford Handbook Of Clinical Medicine Longitudinal split in the squamous lining of the lower anal canal

90% are posterior

Causes: hard feces, trauma, syphillis, herpes, crohn’s disease, anal ca., psoriasis

Diagnosed on PR ± sigmoidoscopy FISSURE IN ANO Fistula in Ano Bailey and love’s short practice of surgery PARKS’ CLASSIFICATION Browse’s Introduction To The Sign And Symptoms Of Surgical Disease CLASSIFICATION BASED ON LEVEL Bailey and love’s short practice of surgery
Fistulas originating anterior to a transverse lie through the anus will course straight ahead and exit anteriorly whereas those exiting posteriorly have a curved tract ending on the 6 o'clock position GOODSALL’S RULE Anorectal Abscess Oxford Handbook Of Clinical Medicine And Browse’s Introduction To The Sign And Symptoms Of Surgical Disease Acute sepsis in the anorectal region

Caused by E.Coli, Streptococcus, Proteus (rarely staphs or TB)

Short (2-3 day) history of increasingly severe, well-localised pain and a palpable hot, tender perianal swelling, swollen affected buttock. ANORECTAL ABCESS Bailey and love’s short practice of surgery Pelvirectal or supralevator

Ischiorectal

Perianal or superficial ischiorectal

intersphincteric

Marginal

Submucous CLASSIFICATION Perianal Hematoma Oxford Handbook Of Clinical Medicine And Browse’s Introduction To The Sign And Symptoms Of Surgical Disease It is not a true hematoma but a thrombosis within the inferior rectal venous plexus

Also called a thrombosed external pile

Precipitating factor straining and stretching of the perineum during second stage of labour

The thrombus causes a surrounding inflammatory reaction of pain and edema PERIANAL HEMATOMA Pilonidal Sinus Browse’s Introduction To The Sign And Symptoms Of Surgical Disease A sinus that contains a tuft of hairs

6cm above the anus

Ingrowing of hair, excites a foreign body reaction and may cause devious secondary tracks which open laterally ± abcesses with foul smelling discharge PILONIDAL SINUS Hair-dressers get theses sinuses between their fingers Rectal Prolapse Oxford Handbook Of Clinical Medicine The mucosa or rectum in all its layer, may descend through the anus

Leads to incontinence in 75%

It is due to a lax sphincter and prolonged straining RECTAL PROLAPSE Browse’s Introduction To The Sign And Symptoms Of Surgical Disease COMPLETE/FULL THICKNESS PROLAPSE(procidenta): the entire rectal wall, muscle and mucosa become displaced through the anus PARTIAL THICKNESS PROLAPSE: only the muscosa prolapses (history very similar to second degree hemorrhoids, instead of discrete anal cushions, there is a circular fold of mucosa TYPES OF
RECTAL PROLAPSE Bailey and love’s short practice of surgery LUMP large, anal region
TIME after defecation or spontaneously when standing walking or coughing
REDUCIBILITY spontaneous or manual

SLIGHT PAIN

PERSISTENT DESIRE TO DEFECATE

BLEEDING

INCONTINENCE OF FECES CLINICAL FEATURES Skin Tags Browse’s Introduction To The Sign And Symptoms Of Surgical Disease Are of varying size and shape are commonly found in the peri-anal area

They represent an exaggeration of the normal wrinkling of the lax anal skin, which must be able to stretch enough to allow defecation

Usually symptomless but may rub or itch

A tag may develop at the lower end of an anal fissure, often called a sentinel tag SKIN TAGS Hemorrhoids/Piles Oxford Handbook Of Clinical Medicine Abnormal enlargements of the anal cushions (spongy vascular tissue) are called hemorrhoids

They are attached by smooth muscle and elastic tissue but are prone to displacement and disruption either singly or together

Their positions are at 3, 7 and 11 o’clock in lithotomy position HEMORRHOIDS/PILES Oxford Handbook Of Clinical Medicine Piles are vulnerable to trauma and bleed readily from the capillaries hence their name, hemorrhoids (running blood in greek)

Because loss is from capillaries, the blood is bright red

As there are no sensory fibers above the dentate line (squamomucosal junction), piles are not painful unless they thrombose when they are protrude and are gripped by the anal sphincter, blocking venouse return Bailey and Love's Short Practice of Surgery 25th Ed. and Norman Browse Surgery Prolonged sitting
Prolonged standing
Lifting heavy objects
Straining bowel movements (constipation)
Straining micturition (BPH or strictures)
Pregnancy
Obesity
Lack of exercise
Lack of dietary fiber
Carcinoma of retum
Paraplegia CAUSES OF
HEMORRHOIDS TYPES OF
HEMORRHOIDS http://www.hemorrhoidtreatmentanswers.com/wpcontent/images/hemtypes.jpg http://www.gothemorrhoids.com/images/grades.jpg Bailey and love’s short practice of surgery Anaemia

Strangulation and thrombosis

Ulceration

Gangrene

Fibrosis COMPLICATIONS Condylomata Accuminata (Anal Warts) Norman Browse, Dorlands Dictionary and Bailey and love’s short practice of surgery A pointed papilloma typically found on the skin or mucous membranes of the anus and the external genital organs.

Caused by a HPV (90%) and can be transmitted sexually

Seen in patients with depressed immune response: Chemotherapy, steroids or HIV

Also known as venereal warts, they are highly contagious. CONDYLOMATA ACCUMINATA
(ANAL WARTS) Bailey and love’s short practice of surgery HPV

Homosexual males

HIV

Immunocompromised patients Risk factors Bailey and love’s short practice of surgery Pruritis

Discharge

Bleeding per rectum

Pain

Obliteration of anal orifice (later stages) SIGN AND SYMPTOMS Clinical Features Anal Cancer Squamous Cell Carcinoma

Cloacogenic (Transitional Cell) Carcinoma

Others:

Adenocarcinoma

Melonoma

Mucoepidermal Types of Anal Cancers http://www.hemorrhoidshemroids.com/soa-aids-amsterdam-condylomata-acuminata-warts-around-anus.jpg Bailey and love’s short practice of surgery Anal bleeding
Mass
Pain
Mucus per rectum
Pruritis
Fecal incontinence (in case of sphincter invasion)
Asymptomatic (25%) SIGN AND SYMPTOMS Bailey and love’s short practice of surgery
Human papilloma virus (16, 18, 31, or 33)
Condyloma
Herpes
HIV
Chronic inflammation (crohn’s disease/fistulae)
Immunosuppression
Homosexuality in males
Cervical/vaginal cancers
STDs
smoking RISK FACTORS Bailey and love’s short practice of surgery ADENOCARCINOMAS:

within the anal canal are usually extension of distal rectal cancers. Rarely may arise from anal glandular epithelium or within a longstanding anal fistula.

MELANOMAS:

Can be found in the transitional zone of the anal canal. It is very rare. Usually presents as a bluish-black soft mass that may mimic a thrombosed external pile. OTHER ANAL MALIGNANCIES Clinical Cases RECENT ADVANCEMENTS http://medtube.net/gastroenterology/medical-pictures/9648-fistula-in-ano-5-of-7 Diseases of the Colon & Rectum:
August 2012 - Volume 55 - Issue 8 - p 870–875
doi: 10.1097/DCR.0b013e31825af532 A total of 12 outpatients (9 women, 3 men) treated for fistulizing perianal Crohn’s disease between 2009 and 2010 were enrolled. The mean age was 43.5 (range, 27–59) years. The fistula was classified as anovaginal in 3 patients, transsphincteric in 7 patients (low in 2, high in 5), and complex (multiple tracts) in 2 patients. Suture Rectopexy
The fixation of the rectum in the pelvis with suture, causes fixation of the rectum from the resultant scarring and fibrosis.

Mesh Rectopexy
Fixation of mesh from the anterior rectal wall to the sacral promontory after posterior mobilization may be used for treatment of rectal prolapse, but it is associated with higher morbidity. Operations for Rectal Prolapse:

Abdominal Procedures for Rectal Prolapse

Perineal Operations for Rectal Prolapse RECTAL PROLAPSE Treatment of Complex Fistula-in-Ano
When presented with a complex fistula, MRI is utilised to evaluate the primary course as well as any secondary extensions. 

Complex anal fistulas may be treated with debridement and fibrin glue injection.

Anal fistula plug may be used for treatment of complex anal fistula disease. 4. Lateral internal sphincterotomy is the surgical
treatment of choice for refractory anal fissure.

5. Anal advancement flap is a surgical alternatives to LIS. ANAL FISSURES Outline of the procedure:
Haemorrhoidal artery ligation reduces the blood flow to haemorrhoids, with the aim of reducing discomfort and bleeding.

It also aims to achieve some shrinkage of haemorrhoids.

Adjunctive treatment is required for large prolapsing haemorrhoids.  Significantly less bleeding at 14 days postoperatively with stapled haemorrhoidopexy compared with conventional haemorrhoidectomy. Efficacy:
Stapled haemorrhoidopexy, compared with conventional haemorrhoidectomy, is associated with less pain up to 14 days postoperatively.

Stapled haemorrhoidopexy is associated with shorter wound healing time, shorter time to return to normal bowel function and shorter length of hospital stay.

In addition, there is a reduction in time to return to normal activity. Procedure:
Excision of a band of the prolapsed anal mucosa membrane above the dentate line, using a specific circular stapling device.

This interrupts the blood supply to the haemorrhoids and reduces the potential for available rectal mucosa to prolapse. Surgical haemorrhoidectomy is usually the treatment of choice for third- and fourth-degree haemorrhoids Clinical need and practice:
 First- and second-degree internal haemorrhoids are generally treated by changing bowel habit, diet and lifestyle, and by using stool softeners or laxatives.

For second-degree haemorrhoids, injection sclerotherapy or rubber-band ligation are used. HAEMORRHOIDS International Journal of Colorectal Disease
2012, DOI: 10.1007/s00384-012-1519-2 The results suggest that patients with perianal abscess have a higher chance of contracting type 2 diabetes mellitus within the first 5 years following their diagnosis.
Conclusions  International Journal of Colorectal Disease
2012, DOI: 10.1007/s00384-012-1519-2 Of the total 8,514 sampled subjects, the incidence rate of diabetes per 100 person-years was 1.87;

the rate among patients with perianal abscess was 3.00;

and was 1.65 among comparison patients.
Results  International Journal of Colorectal Disease
2012, DOI: 10.1007/s00384-012-1519-2
To find out whether perianal abscess is a prediabetes condition or the initial presentation of type 2 diabetes. Using a population-based dataset, this study aimed to explore the risk of type 2 diabetes following perianal abscess. Background Po-Li Wei, Joseph J. Keller, Li-Jen Kuo and Herng-Ching Lin Increased risk of diabetes following perianal abscess: a population-based follow-up study International Journal of Colorectal Disease
2012, DOI: 10.1007/s00384-012-1519-2 Diseases of the Colon & Rectum:
August 2012 - Volume 55 - Issue 8 - p 870–875
doi: 10.1097/DCR.0b013e31825af532 The median number of injections per patient was 7 (range, 4–16).
The mean length of follow-up was 17.5 (range, 5–30) months;
75% of patients (9 of 12) reached complete cessation of fistula drainage, and 3 patients (25%), all with transsphincteric fistula, showed improvement.
Comparison of overall follow-up scores on the Perianal Crohn’s Disease Activity Index with baseline showed significant improvement (p = 0.002). No adverse side effects were noted. RESULTS Diseases of the Colon & Rectum:
August 2012 - Volume 55 - Issue 8 - p 870–875
doi: 10.1097/DCR.0b013e31825af532 Adalimumab was injected locally along the fistula tract and around the internal orifice every 2 weeks. INTERVENTION: Diseases of the Colon & Rectum:
August 2012 - Volume 55 - Issue 8 - p 870–875
doi: 10.1097/DCR.0b013e31825af532 This was a prospective, uncontrolled, open-label observational study performed at a university tertiary care center. DESIGN AND SETTING Diseases of the Colon & Rectum:
August 2012 - Volume 55 - Issue 8 - p 870–875
doi: 10.1097/DCR.0b013e31825af532 The aim of this study was to investigate the effectiveness and safety of local injection of adalimumab along the fistula in the treatment of perianal Crohn’s disease. OBJECTIVE Diseases of the Colon & Rectum:
August 2012 - Volume 55 - Issue 8 - p 870–875
doi: 10.1097/DCR.0b013e31825af532 Randomized controlled trials have demonstrated the effects of systemic therapy with adalimumab, a fully humanized monoclonal antibody against tumor necrosis factorα. Background Diseases of the Colon & Rectum:
August 2012 - Volume 55 - Issue 8 - p 870–875
doi: 10.1097/DCR.0b013e31825af532 Tonelli, Francesco M.D.1; Giudici, Francesco M.F1; Asteria, Corrado Rosario M.D2 Effectiveness and Safety of Local Adalimumab Injection in Patients With Fistulizing Perianal Crohn’s Disease: A Pilot Study http://www.sciencedirect.com/science/article/pii/S0011384001700573 Mesh Rectopexy Abdominal Procedures for Rectal Prolapse
1. Procedures incorporating transabdominal rectal fixation are typically the procedure of choice for the treatment of rectal prolapse.

2.Rectopexy is a key component in the abdominal approach to rectal prolapse. 5. Complex anal fistulas may be treated by the use of a seton. 4. Endoanal advancement flaps may be used for treatment of complex anal fistula disease (mucosal advancement flaps are raised adjacent to the internal opening to provide tissue coverage of tract opening and subsequently allow the tract to heal and close) 3. Simple anal fistulas may be treated with debridement and fibrin glue injection. 1.Patients with acute anorectal abscess should be treated with incision and drainage.

2. Antibiotics have a limited role in the treatment of uncomplicated anorectal abscess

3. Antibiotics may be considered in patients with
significant cellulitis, underlying immunosuppression,
or concomitant systemic illness. GUIDELINES FOR THE MANAGEMENT OF
PERIANAL ABSCESS PERIANAL ABSCESS The procedure usually involves cutting a portion of the internal anal sphincter muscle. This helps the fissure heal and decreases pain and spasm. 2. Anal fissures may be treated with topical nitrates, although nitrates are marginally superior to placebo with regard to healing.

3. Botulinum toxin injection has been associated with healing rates superior to placebo. Nonoperative treatment continues to be safe, has few side effects, and should usually be the first step in therapy.

Sitz baths

Bulking agents

Topical anesthetics or anti inflammatory ointments GUIDELINES FOR THE MANAGEMENT OF ANAL FISSURES (2004) Efficacy:
Less postoperative pain

Resolution of haemorrhoids, and

Relief of symptoms such as bleeding, prolapse, swelling, pain, soreness and itching in the short and long term. The patient is under general anaesthesia.

Using a proctoscope, the haemorrhoidal arteries are ligated with sutures to remove the flow of blood to the haemorrhoids.

For larger prolapsing haemorrhoids, an adjunctive mucosal plication procedure is done.

The prolapsing mucosa is fixed by haemorrhoidopexy. Prolapsed tissue is pulled into a device that allows the excess tissue to be removed while the remaining hemorrhoidal tissue is stapled. This restores the hemorrhoidal tissue back to its original anatomical position. Stapled haemorrhoidopexy, using a circular stapler specifically developed for haemorrhoidopexy, is recommended as an option for people in whom surgical intervention is considered appropriate for the treatment of prolapsed internal haemorrhoids. STAPLED HAEMORRHOIDOPEXY AS TREATMENT OF HAEMORRHOIDS
Surgical haemorrhoidectomy is usually performed by the Milligan-Morgan (open) or Ferguson (closed) procedure. SURGICAL HAEMORRHOIDECTOMY Indications and current treatments:
Grade I or II haemorrhoids may be treated by diet modification.

Interventional treatments include rubber band ligation and injection sclerotherapy.

Treatments for grade III and IV haemorrhoids include surgical excision of the haemorrhoids (haemorrhoidectomy) or stapled haemorrhoidopexy. International Journal of Colorectal Disease
2012, DOI: 10.1007/s00384-012-1519-2 analysis: patients with perianal abscess were more likely to have received a diagnosis of diabetes than comparison patients during the 5-year follow-up period;
Censoring cases that died from nondiabetes causes and adjusting for patient geographic location, urbanization level, monthly income, hypertension, coronary heart disease, hyperlipidemia, obesity, and alcohol abuse/alcohol dependence syndrome at baseline. Results (cont..) International Journal of Colorectal Disease
2012, DOI: 10.1007/s00384-012-1519-2 Data source: Longitudinal Health Insurance Database 2000.

1,419 adult patients with perianal abscess in the study group and 7,095 randomly selected subjects in the comparison group.

Association between being diagnosed with perianal abscess and receiving a subsequent diagnosis of diabetes within 5 years were found out. Methods Diseases of the Colon & Rectum:
August 2012 - Volume 55 - Issue 8 - p 870–875
doi: 10.1097/DCR.0b013e31825af532 This pilot study suggests that a high local concentration of adalimumab favors prompt and definitive healing of the fistulous tract in patients with perianal Crohn’s disease.

Future randomized trials are needed to determine the relative risks and benefits of available anti-TNF-α blockers and the optimal mode of administration in the treatment of fistulizing perianal Crohn’s disease. CONCLUSIONS Diseases of the Colon & Rectum:
August 2012 - Volume 55 - Issue 8 - p 870–875
doi: 10.1097/DCR.0b013e31825af532 The primary end point of the study was the proportion of patients in whom complete or improved healing of fistulas was observed at follow-up, with improvement based on the number of daily changes of sanitary pads. MAIN OUTCOME MEASURES Evaluation of Rectal Prolapse
The initial evaluation of a patient with rectal prolapse should include a complete history and physical examination.

Additional tests such as a colonoscopy and barium enema can be used selectively to define the diagnosis and identify other important pathology GUIDELINES FOR THE MANAGEMENT OF RECTAL PROLAPSE Treatment of a Simple Fistula-in-Ano
Simple anal fistulas may be treated by fistulotomy( surgical opening of a fistulous tract. They can be performed by simple division of the tract, or gradual division and assisted drainage of the tract by means of a seton).

Concomitant fistulotomy with incision and drainage may be considered in patients with anorectal abscess and fistula GUIDELINES FOR THE MANAGEMENT OF
FISTULA-IN-ANO FISTULA-IN-ANO This procedure is an efficacious alternative to conventional haemorrhoidectomy or stapled haemorrhoidopexy in the short and medium term, and that there are no major safety concerns. HAEMORRHOIDAL ARTERY LIGATION
The Ferguson The Milligan-Morgan It is a modified version of the Milligan-Morgan technique, in which the wound is closed with a continuous suture to promote healing Involves dissection of the haemorrhoid and ligation of the vascular pedicle.
The wounds are left open to heal naturally.
It is thought to be relatively safe and effective.
But because the anodermal wounds are left open healing is delayed, which may result in discomfort and prolonged postoperative morbidity. The Ferguson The Milligan-Morgan Anal fissure

Anal stenosis

Incontinence

Fistula

The recurrence of haemorrhoidal symptoms. Pain

Bleeding

Perianal sepsis Long term Short term A number of postoperative complications are associated with surgical haemorrhoidectomy Posterior Midline Anterior Midline Occurs in 90% of cases

Due to exaggerated shearing forces acting at the site of defecation

Posterior midline has less elastic anoderm Occurs in 10% of cases

More common in females

May arise following vaginal delivery Hair penetrates the skin Dermatitis Infection Pustule formation Sinus Formation Hair gets sucked into sinus by negative pressure Further irritation and granulation tissue Pus forms Multiple Discharging sinuses Bailey and Love Short Practice of Surgery 25th Edition Fistula Tracts Greater anal sphincter muscle involvement

Presence of more than one anal fistula (secondary tract and/or with abscess cavity)

Anal fistula associated with other diseases (eg. Crohn's disease, tuberculosis) Low intersphincteric or transphincteric type single short tract

The external opening is close to the anal verge

The internal opening is lower (closer to the anal verge)

Absence of secondary tract or abscess cavity

Absence of association with other disease Simple Fistula Complex Fistula Complex Anal Fistula THANK YOU A 46 year old male presents with bright red blood on the surface of his stools and on toilet paper after wiping with burning and tearing sensation on defecation. Digital Rectal Exam was not possible due to severe pain in the anal region. What is your diagnosis? DIAGNOSIS: Anal Fissure

DIFFERENTIAL DIAGNOSIS: Trauma, Complication of skin disease, Syphilis, Chlamydia, Intrasphincteric abscess, Anal Fistula, Acutely Thrombosed Hemorrhoid, Carcinoma of Anus. A 50 year old male complains of recurrent discharge from the perianal region for 5 years. He also complains of pain in the perianal region on sitting and coughing. He has a history of recurrent fever and pruritis. On examintion, an indurated tract was seen with circular granulation tissue which exuded pus on compression, it was warm to touch and erythema was present. What is your diagnosis? DIAGNOSIS: Anal Fistula A 55 year old man presents to his primary care physician’s office with complaints of small streaks of bright, red blood in both his toilet bowl and toilet paper after wiping. He denies having pain with defecation, but does complain of a burning, itching sensation in the perianal region. He has no history of inflammatory bowel disease and had a normal colonoscopy approximately 5 years ago. Rectal exam reveals a purple palpable elliptical mass extending from the anal to perianal skin and mildly painful to palpation. What is your diagnosis? DIAGNOSIS: Perianal Hematoma

DIFFERENTIAL DIAGNOSIS: Internal Hemorrhoid, Anal Fissure, Abscess, Anal Prolapse, Anal Cancer, Anal Skin Tags. A 65 year old male presents with a feeling of ‘something coming out’ of the anus during defecation or slight straining. He stated that initially a mass protruded during bowel movements, and retracted afterwards. Later, he had to manually replace the prolapsed mass. This time, he could not reduce the prolapsed mass. He does not complain of bleeding per rectum. His history was only significant for chronic constipation for 10 years. Physical examination revealed a long segment of prolapsed bowel protruded through the anus. What is your diagnosis? DIAGNOSIS: Rectal Prolapse

DIFFERENTIAL DIAGNOSIS: Hemorrhoids, Intussusception, Proctitis (Inflammation Of The Rectal Mucosa), Ulcerative Colitis. A 46 year old man presented with 3 day history Increasingly severe, well localised pain along with a palpable swelling at the perianal region. Pain is throbbing in nature and is aggravated by sitting and defaecation. Examination reveals a hot, tender and fluctuating perianal swelling. Digital examination of the rectum reveals a tender, indurated bulge on the corresponding aspect of the anal canal above the anal swelling. DIAGNOSIS: Perianal Abscess TREATMENT GUIDELINES ANATOMY OF THE
ANAL CANAL Fistula in Ano Chronic abnormal communication usually lined by granulation tissue which runs outward from anorectal lumen (internal opening) to external opening on skin of buttock.

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