UG class

1. Case Scenarios
32 year old male patient with 3 weeks h/o constipation, painful
defecation, passing pellet stools, minimal fresh bleeding P/R
Diagnosis
Rx
40 yr female with painless rectal bleed, constipation, pruritus ani
for 4 weeks. Previous h/o some injection into anal canal,
details unknown.
Dx, Rx
60 yr male with painless fresh bleeding p/r, altered bowel habit
for 3 months
Ddx
Invg, Rx

2. DISEASES OF ANAL CANAL
Topics: 1.Anorectal malformation
2.Pilonidal sinus
3.Fissure in ano
4.Haemorrhoids
5.Anorectal abscess(Peri-anal abscess)
6.Fistula in ano

3. ANATOMY
4 cm length
Levator to anal verge
Mucosa
ectoderm: squamous
dentate line
endoderm: columnar
Muscle coat:
external sphincter
internal sphincter
Intersphincteric space
Anorectal ring

4. PILONIDAL SINUS
Sepsis in natal cleft area or level of 1st coccyx segment
Sites: natal cleft, web space hand, axilla, umbilicus
Aetiopathogenesis: acquired
occupational – hair stylist, jeep drivers
hairy men in 20-30 yrs
Loose hairs from back ---- penetrate pits in natal cleft
sepsis
Abscess cavity + tuft of hairs sinus tracts

5. C/F: recurrent infections, abscess, h/o I&Ds
Multiple sinus
Tender lump s/o abscess
Scars of prev surgery
Rx: 1.Conservative
- first mild attack
- Antiseptic wash
- hair removal
- Avoid prolonged driving (truckers)

6. 2.Acute pilonidal infection
-Incision and drainage
-Antibiotics
-Hair removal
-Local hygiene
-Elective Surgery -- once infection controlled
a. Excision of cavity along with tracks, cavity heals by
secondary intention
b.Bascom technique: lateral incision to remove abscess
cavity, midline incision to remove pits.
c.Modified Limberg flap

8. FISSURE IN ANO
An anal fissure is a painful linear tear in the distal anal canal
Acute - < 6 weeks, mucosal tear
Chronic > 6 weeks, full thickness ulcer
Etiology: vicious cycle constipation passing
hard stool
painful mucosal tear straining at stool
defecation spasm of int. sphincter

9. FISSURE IN ANO
Site: posterior midline (98%) poorly perfused
hypertonicity of sphincter
anterior (2%)
C/F: painful defecation
passing pellet stools
bleeding P/R minimal
constipation
O/E: Acute: painful P/R
spasm of int. Sphincter
Chronic: sentinel pile
indurated ulcer posterior midline,
sphincter fibres seen, spasm +

10. Atypical fissure in ano - away from midline
Crohn’s, HIV, SCC anal canal
Treatment: 1.conservative break the cycle
Relieve shpincter spasm diltiazem cream
GTN cream
botulinum toxin injection
Relieve pain Sitz bath
Relieve constipation Laxatives
Diet - high fibre diet, 3 L fluids

11. Surgical: 1.Lateral internal sphincterotomy
2.Manual anal dilatation(MAD)

12. HAEMORRHOIDS
Defn: dilated venous saccules in anal cushions
Anal cushions – highly vascular tissue near dentate line
Sup.haemorrhoidal artery – vein plexus
Etiology: Primary Secondary
pregnancy
pelvic tumour
CCF, constipation
rectal cancer
Anorectal varices

13. Types: 1.Internal – above dentate line
covered by mucosa
2.External perianal area
covered by skin
3.Intero-external prolapsing internal piles
Position: 3, 7, 11’O clock in lithotomy position
Haemorrhoids

14. Grading: 1st degree congested anal cushions
2nd degree prolapse, reduce spontaneously
3rd degree prolapse, manual reduction
4th degree permanent prolapsed piles
C/F: painless, bright red bleeding, ‘flash in pan’
pruritus ani
mucus discharge
constipation
Complications: anemia
thrombosis

15. Treatment
1. conservative: Gr I- dietary
2.Sclerotherapy Gr II -5% phenol in almond oil
STD
3.Banding Gr I, II
4.Haemorrhoidectomy Gr.III /IV
Cryosurgery, Stapled haemorrhoidectomy, Laser

17. ANORECTAL SEPSIS
Defn: pyogenic infection of anal glands in the inter-sphincteric
space, which later spreads to adjacent anatomical spaces.
Bacteriology: E.coli
Staph. aureus
Streptococcus, bacteroides
Risk factors: diabetic
Immunocompromised
Crohn’s
Low –socioeconomic strata
Poor local hygiene

18. TYPES
1. Perianal follicle, sebaceous gland, haematoma
2. Submucous infected fissure, laceration
3. Ischiorectal anal gland, perianal abscess, FB
4. Pelvirectal pelvic abscess

19. TREATMENT
C/F: severe pain, very tender swelling
‘do not wait for fluctuation’
Incision and drainage
Antibiotics
Ischiorectal abscess: diabetics
fever with chills
excruciating pain, sepsis
I&D by cruciate incision

20. FISTULA IN ANO
Defn: an abnormal communication between anal canal/rectum
and the perianal skin.
Etiopath: Majority arise from anal gland infection -------
abscess --- tracks into lumen and to exterior
Crohn’s disease, Ulc. Colitis
TB
Ca.rectum
Gut flora in anorectal abscess suggestive of underlying fistula

21. ANATOMICAL CLASSIFICATION
According to position and relation to the sphincters(internal &
external)
Superficial subcutaneous/submucous
Intersphincteric low anal fistula( 95% )
Trans-sphincteric
Suprasphincteric high fistula
Extrasphincteric
Goodsall’s law

23. FISTULA IN ANO
C/F: h/o anorectal abscess I & D
Recurrent perianal infection
O/E: external opening of fistula
Scars of previous Sx
DRE – track felt as induration
Proctoscopy – internal opening sometimes seen
Most important – relation of track to the anal sphincters
Invg: Fistulogram
MRI – best
Endoanal US

24. TREATMENT
Principles: Laying open the track, heal by granulation tissue
Low anal fistula- below the anorectal ring Fistulotomy
Fistulectomy
High fistula - lower track laid open, a seton is passed thru upper
track and tightened over 3-4 weeks
Track is gradually divided along with the sphincters
Crohn’s – antibiotics, anti-TNF - infliximab