2. Anatomy Most distal portion of the alimentary canal. Extends for a distance of about 3 cm from the anorectal ring to the hairy skin of the anal verge. Anus provides continence for flatus and faeces.
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4. Internal hem. plexus Anal crypts and columns Dentate line Int. sphincter Anal gland White line External sphincter
5. Nerve supply Below the dentate line, cutaneous sensations conveyed by afferent fibers in the inferior rectal nerves. Above the dentate line : parasympathetic fibres
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8. Internal sphincter Involuntary sphincter Innervated by autonomic nervous system Formed by extension of rectal musculature
10. Fecal incontinence The principal function of the anal canal is the regulation of defecation and maintenance of continence. Evaluated by manometry, defecography and electromyography.
22. ANAL FISSURE OR FISSURE-IN-ANO Linear ulcer of lower half of anal canal Posterior fissure is most common Anterior fissures commoner in women than men Fissure in any other location : suspect Crohn’s disease Hydradeinitissuppuritiva STDs
24. pathogenesis passage of large, hard stools, which may be the initiating factor; inappropriate diet; previous anal surgery; childbirth; and laxative abuse.
27. Acute fissure in ano Short history Painful No sentinel pile on examination Managed conservatively
28. Chronic fissure in ano Recurrent acute fissure Associated with sentinel pile Can be treated conservatively initially but may require surgery Sentinel pile : a skin tag formed due to chronic inflammation and fibrosis
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30. treatment Non surgical Surgery AIM: To increase the blood supply to promote healing of the ulcer/fissure
31. Non surgical treatment Stool bulking agents Hot tub baths/ Sitz bath Local ointments Lignocaine Nitroglycerine Dietary modifications Botox injections
32. surgical Sphincterotomy Internal anal sphincter is cut to relieve the spasm and in turn increase blood supply to the fissure Midline sphincterotomies cause key hole defects, hence lateral sphincterotomy is done. 2 types : Open Closed
35. Anal sepsis and fistulae Anorectalabcess – acute form of anal sepsis Fistula in ano – chronic form of the disease process Anal fistula : communication between an internal opening in the anal canal and an external opening through which an abscess drained.
36. etiology Infection of obstructed anal glands : Most common cause Trauma Foreign body Tuberculosis Actinomycosis Inflamatory bowel disease
40. Perianal abscess Results frtom suppuration of anal gland or suppuration of a thrombosed external pile Lies in the region of subcutaneous portion of external sphincter
41. Clinical features Severe pain in perianal region Difficulty in sitting Tender smooth and soft swellling in the perianal region
43. Ischiorectalabcess Due to extension of intermuscularabcess through external sphincter Can be blood born as well Fat in fossa more prone for infection as it is least vascularized Both these fossa are connected one fossa infection may lead to the infection on other side HORSE SHOE ABCESS
44. Clinical features Tender, indurated, brawny swelling in the skin over ischiorectalfossa Fever Swelling is not well localized so it is difficult to elicit fluctuation.
45. treatment Cruciate incision and drainage Pus for c/s Look for any internal opening (for presence of internal fistula)
48. Fistula in ano Etiology Cryptoglandular sepsis(most common) Trauma Crohn’s disease Malignancy Radiationtuberculosis,actinoymycosis
49. Clinical features Persistent drainage from internal or external opening Indurated tract can be palpable on per rectal examination . External opening easily found but finding the internal opening can be a challenge
50. Goodsall’s rule ‘In general, fitulas with external opening anteriorly connect to internal opening by a short,radial tract.’ Fistulas with external opening posteriorly track in curvilinear fashion to posterior midline. EXCEPTION : anterior external opening >3cm from anal verge usually follow curved track to posterior midline
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52. Classifications of fistula in ano Park’s classification High and low fistula in ano Simple and complex fistula in ano
56. fistulotomy ‘Laying open of the fistula tract from its termination to source’ Applied mainly to intersphincteric and transphincteric fistula involving less than 30% of voluntary muscle. Staged sphincterotomy : part of sphincter is divided and rest tied upon by a seton.
59. setons Latin for Bristle Loose and tight setons : depending upon the intent of cutting through the muscle. After tying, these are tightened in intervals of weeks. ‘Cheese wire cutting through ice’ They gradually cut through the muscles without springing them apart
62. Pilonidal sinus(jeep bottom) Pilus= hair , nidus = nest Of infective origin Occurs in sacral region between the buttocks Other sites : umbilicus, web spaces of fingers(in barbers)
65. Clinical features Serosanguinous or purulent discharge Throbbing and persistent pain Sometimes tender swelling in the midline Tufts of hair may be seen in the opening of sinus
66. treatment Excision of the sinuses Laying open the sinus Z- plasty Rotation flaps Bescom’s operation Karydaki’s operation
67. Anal intraepithelial neoplasia Virally induced dysplasia Risk factors : anoreceptive intercourse and HIV Usually patients are asymptomatic Based on degree of dysplasia : AIN I, AIN II, and AIN III AIN II and III have chances of progressing to invasive carcinoma
68. Clinical features 30% asymptomatic Suspicious areas are raised, scaly, white, erythematous, pigented or fissured.
69. management Multiple mapping biopsies Excision followed by colostomy or flaps Topical imiquimod or retinoids have some effect on progression of diesease.
70. Non malignant strictures Spasmodic : due to anal fissure. Organic : Postoperative Irradiation stricture Senile anal stenosis Lyphogrnulomainguinale Inflamatory bowel disease Endometriosis
71. Clinical features Increasing difficulty in defecation ‘Pipe stem’ stools. Stricture can be palpated as annular or tubular on DRE.
72. treatment Dilatation by bougies. Anoplasty. Colostomy. Rectal excision and coloanalanastomosis.
73. Malignant tumors Below dentate line : SCC Above dentate line : basaloid, cloacogenic or transitional carcinomas.
75. Clinical features Pain Bleeding Pruritus Fecal incontinence as a result of sphincter invasion. Palpable as indurated, irregular, tender ulcers.
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77. management Primary treatment : chemoradiotherapy CMT(combined modality treatment) 5-FU with mitomycin C or cisplatin Resection indicated in Small marginal tumors Persistent or recurrent disease followed by colostomy
