ANORECTAL

PROBLEMS
By
Dr.Ahmed Noureldin Ahmed
(MBBS,DCH,DTM&H (Cairo
PHC , Umm-Ghoilina
Rectal Anatomy
 Anorectal Diseases
:We will discuss to day 10 topics
Hemorrhoids- 1
Rectal Prolapse-2
Solitary Rectal ulcer Syndrome-3
Anal Fissure-4
Perianal Abscess-5
Anal Fistula-6
Anorectal Infection-7
Pruritus Ani-8
Fecal Incontinence-9
Squamous Cell Carcinoma of anus-10
 -Hemorrhoids 1
are abnormally enlarged and dilated veins around
.anus
?What are the causes
It can be hereditary with congenital weakness of
the vein walls.
In men, due to erect posture there is high
pressure in rectal veins.
Straining by constipation and over purgation.
Dysentery may aggravate latent hemorrhoids.
Haemorrhoids are also common among
pregnant women. The pressure of the foetus in
the abdomen, as well as hormonal changes,
.cause the haemorrhoidal vessels to enlarge
 .
.
 Hemorrhoids
A- Internal hemorrhoids
Are a plexus of superior hemorrhoidal
veins located above the dentate line,
which are covered by mucosa , they are a
.normal anatomy that occur in adults
They are occur in three primary location,
RT anterior, Rt posterior and Lt lateral .
Smaller hemorrhoids may
occur between
these primary
locations
.
 Views of internal hemorrhoid
dentate line and ext,hemorrhoides
 B- External hemorrhoids
arise from the inferior hemorrhoidal►
vein located below the dentate line
.and covered with squamous epithel
.of the anal canal or perianal region
Hemorrhoids become symptomatic ►
as a result of activities that increase
:venous pressure such as
Activities That increase the Venous
Pressure
Straining at school ■ Constipation■
Prolonged sitting ■Low fiber diets ■
,Pregnancy ■Obesity■
Which result in distention and enlargement of
.Superior and/or inferior hemor.veins plexus
With time → redundancy and enlargement of
these veins may develop and result in bleeding
. or Protrusion
Thrombosed external hemorrhoids (long arrow)
)and perianal tags from "old"disease (short arrow
.
Prolapsed internal hemorrhoids,
grade IV (long black arrow).
The dentate line
(short black arrow) is indicated, and
. a small polyp (white arrow) is visible
Symptoms and signs
 Symptoms and signs
Internal hemorrhoids patient
complain of bleeding and mucoid
discharge. Bleeding is bright red
blood range from streaks of
blood,visible on toilet paper to
bright red blood that drips after
.bowel movement
 .

This 's what hemorrhoids feels

like
 Stages of Internal Piles
:There are 4 stages of Internal Piles
Stage 1 : Piles confined to the anal canal ■
Stage 2 : piles prolapse during straining and■
.reduces spontaneously
Stage 3 : when prolapsed require manual reduction■
Stage 4: become chronically prolapsed■
Discomfort & pain are unusual in internal piles, which
occur only when there is extensive inflammation and
thrombosis of irreducible internal hemorrhoids. Or
with thrombosis of external pilse
 On Examination
:Non-prolapsed Internal hemorrhoids►
Are not visible, but may protrude with straining while the
.physician spreads the buttocks
:Prolapsed Internal hemorrhoids►
Are visible as protuberant purple nodules covered by mucosa
:External hemorrhoids►
Are readily visible on perianal inspection in the form of perianal
nodules covered with skin that may reach several centimeters
.in size
The peri-anal region►
should be examined for other signs of disease such as
fistulas , fissures,skin tags,or dermatitis
Position for Rectal Digital
(Examination (PR
 Treatment
Conservative ttt in stage 1 and 2
Decrease straining with defecation ■
High Fiber Diets ■
Increase fluid intake with meals ■
Mucoid discharge prevented by cotton ball■
tucked to anal opining
:For edematous , prolapsed pilse■
gentle manual reduction•
.supp.that contain anesthetic and astringent•
warm sitz baths•
 Surgery
Injection of Sclerotherapy►
Rubber Band Ligation►
Surgical Excision►
 Thrombosed External Piles
Thrombosis of external hemorrhoidal
plexus results in a peri anal hematoma.
It commonly occur in healthy young adults
Which is precipitated by coughing,heavy lifting
.Or straining at stools
It is characterized by : acute onset of
painful,tense, and bluish perianal nodule
covered with skin. Pain is severe within the
first few hours and gradually decrease over
.2-3days
External hemorrhoid after seven
.days of thrombosis
 Treatment

Warm Sitz Baths ■

Analgesics ■
Ointment ■
In the first 48 hrs. removal of the clot
.under local anesthesia
 ?How is a Hemorrhoid treated
Warm soaks ( sitz baths) several times a day can
significantly reduce the pain, especially after a painful
bowel movement. Topical anesthetics can also be used
to reduce the pain of a thrombosed hemorrhoid. Anti-
inflammatory topical treatments (such as
proctoFoam® HC (hydrocortisone acetate 1% and
pramoxine hydrochloride 1%) and proctoCream® HC
2.5% (hydrocortisone acetate 2.5%) can soothe the
irritation and pain. Hydrocortisone is a commonly used
anti-inflammatory agent and is found in a number of
medications. Astringent compresses can also be used
for soothing purposes
Bulk fiber laxatives, such as Citrucel are often
recommended to reduce strain on the rectal area. Fiber
may create softer larger stools, reducing straining and
helping sensitive tissue heal faster, naturally
 How can a Hemorrhoid be
prevented
Prevention of hemorrhoids involves:
normal bowel movements. Avoiding
the straining associated with constipation is
very important. Stool softeners and food or
supplements that add bulk to stool are
often used. Bulk forming agents include
bran and other whole grains, fiber
. supplements, fruits and vegetables
Proper hydration to keep stool soft is
important therefore increasing water
intake beneficial
 Rectal Prolapse- 2
It is protrusion through the anus
of some or all the layer of the
, rectum . It arises from chronic
excessive straining at stool in
conjunction with weakening of
pelvic support structures
Initially prolapse reduces
spontaneously after defecation, with
time the rectal mucosa becomes
.chronically prolapsed
 Symptoms
Mucous Discharge ■
Rectal Bleeding ■
Fecal Incontinence ■
Sphincteric Damage ■
 Anal mucosal prolapse (Lt ) and
. ) full-thickness rectal prolapse (Rt
 Solitary Rectal Ulcer Syndrome
:Characterized by
Anal Pain♣
.Excessive straining at stools♣
.Passage of mucus and blood♣
.It is most commonly seen in young women
Proctoscopy reveals → either shallow ulceration (single or
multiple) or nodular mass located anteriorly
cm above anal verge 6-10
.Biopsy is diagnostic
Treatment
; decrease straining at stools►
use bulking agents ►
 :Bulking Agents
Dietary Fibers- 1
Wheat Bran- 2
Methyl Cellulose- 3
Mucilaginous gums – sterculia-4
Mucilaginous seeds and seed- 5
coats, e.g. ispaghula husk
(Fybogel Sachets(
Chronic solitary ulcer (arrow). The only way to confirm
that this lesion is not a cancer is to obtain a biopsy. This
.lesion was removed, and further tests showed no cancer
Anal cancer (arrow). This had been treated for 3 months with steroid
suppositories although the patient had never had a physical
examination. Simple inspection of the external anal area allowed the

.physician to identify this aggressive tumor

 Anal fissures
Anal fissures are linear or rocket
.shaped ulcers , usually < 5 mm in length
It occurs commonly in the post. midline , but
.10% occur anteriorly
it is caused by trauma to the anal canal■
during defecate hard stool
patients c/o of severe, tearing pain during ■
.defecation followed by throbbing discomfort
Constipation due to fear of pain ■
 On Examination
By inspection of the anal verge while gently►
separating the buttocks acute fissures look
.like cracks in the epithelium
Chronic fissures result in fibrosis and the►
development of skin tag at the outer-most
)edge ( sentinel piles
.PR may cause severe pain►
 Acute posterior fissure (arrow). Anterior and posterior fissures are
most common. If fissures are located laterally, other etiologies must be
considered. Fissures can often be identified by merely spreading the
glutei but generally require anoscopy
Chronic fissures may present as an
external perianal tag, or sentinal tag
.)(black arrow
The proximal end may also have
granulation tissue that appears as an
anal polyp (white arrow). When the
condition is this advanced, a lateral
.sphincterotomy is usually required
 Treatment
Fiber Supplements■
Warm Sitz Bath■
Topical Agents: 1% hydrocortisone oint■
Nitroglycerin Oint. Bid for 6-8 Wks % 02-0.5■
Recently, injection of Botulinum Toxins( 20 Units) into■
internal anal sphincter, induce healing in 90% of
.Chronic Anal Fissure
Surgery → Lateral Partial Internal Sphincterectomy■
 Perianal Abscess
is infection of anal glands located at►
the base of the anal crypts at the
. dentate line
:Other causes►
.anal fissure , and crohn’s disease
 Symptoms
Continuous , throbbing Perianal Pain ♣
Erythema , fluctuant mass , is found in ♣
thew peri anal region or in the ischio-rectal
.Fossa on P/R examination
:Treatment
Local incision and drainage
Ischio – rectal abscess require drainage in►
the operating room
Sites of Perianal Abscesses
 Peri anal Fistula
Most often arises in an anal crypt■
Usually preceeded by an anal abscess■
In patients with fistula that connect to rectum ,other■
disorders such as : Crohn’s dis,lymphogranuloma
venerium, rectal TB and carncer should be considered
Fistulae are associated with purulent discharge ,that■
may lead to itching,tenderness and pain
Treatment
By incision or excision under anaesthesia
 Common sites of anal fistulae
Note subcutaneous fistulae do not traverse the
sphincters, whereas low and high fistulae do

.
.External site of perianal fistula
 .External site of perianal fistula
This patient presented with "just a little blood
when I wipe." When anoscopy revealed no anal
pathology
closer inspection allowed the physician to identify
. this papular area
The wooden end of a cotton-tipped applicator
was inserted 3 cm confirming a fistula, and the
patient was referred for surgery. In addition to
simple fistulotomy, treatments include
cutting or draining setons, endo-anal mucosal
advancement flaps, sliding cutaneous
advancement flaps, fistulectomy with muscle
. repair and fibrin glue injection
 Blood on the end of a cotton-tipped
applicator being withdrawn from a fistula
.that could easily have been missed
 Anorectal Infections
Proctitis
Is an inflammation of the distal 15 cm of
.the rectum
It is characterized by anorectal
discomfort , tenesmus ,
constipation and discharge
:Most cases are sexually transmitted e.g
N.Gonorrhea ☻ Treponema Pallidum☻
Chlamydia trachomatis ☻H.S. type 2☻
Venereal Warts☻
 Procto-colitis
Is an inflammation that extends above the ■
.rectum to sigmoid colon or more proximally
:It is caused by different organisms such as■
Campylobacter ☻E. histolytica☻
Shigella ☻E.Coli☻
It is manifested by : Frequent small volume ►
,bloody diarrhea , urgency and tenesmus
 Pruritus Ani
It is characterized by perianal itching and
discomfort
:Causes
Over anal hygene associated with fistula fissures- 1
, prolapsed hemorrhoids,skin tags, and minor
.incontinence
Over cleaning with soaps may lead to irritation- 2
or contact dermatitis
Pinworm 4-Candidiasis-3
Scabies 6-Condylomata acuminata- 5
Idiopathic- 7
Perianal dermatitis caused by
.chronic pruritus ani
 Treatment
Treat the cause- 1
Good cleaning with tap water only- 2
followed by gentle drying after bowel
movement
A piece of cotton ball tucked to anal- 3
opening to absorb perspiration or
fecal seepage
Anal ointment and Lotion should be- 4
avoided as it may exacerbate the
.condition
.)Anal tag (arrow
 Fecal Incontinence
Fecal incontinence is present in up to
10% of the elderly
There are 5 principles for bowel
:continence
Solid or semi solid Stools- 1
A distensible rectal reservoir- 2
A sensation of rectal fullness- 3
Intact pelvic nerves and muscles-4
The ability to reach a toilet in - 5
proper time
 Minor Incontinence
many patients c/o of slight soilage of
:undergarment, which occur in
After bowel movement■
With straining or coughing■
With local anal problems which make anal■
sphincter not work properly such as
hemor. , skin tags
in ch.diarrhea,IBS & ulcerat.proctits ■
Elderly may require more time or■
assistance to reach a toilet
Elderly patient with chronic constipation■
may develop stool impaction leading to
overflow incontinence
 Major Incontinence
Complete uncontrolled loss of stool
means problem with shincteric
.damage or neurological damage
:Causes of sphincteric damage include►
Traumatic Childbirth ■ Episeotomy■
Anal Surgery ■Physical Trauma■
:Causes of neurological damage includes►
Obstetric trauma ■ Aging■
Dementia ■ Multiple Sclerosis■
Spinal Cord Injury ■ Cauda Equina Syndrome■
DM■
 Treatment
Bulking Agents- 1
(Anti-diarrheals ( Lopramide 2mg- 2
Anal Sphincter exercise-3
Treat the cause if possible- 4
Surgery in Major incontinence , if- 5
medical treatment fails
 SQUAMOUS ( EPIDERMOID ( CELL
CARCINAMA OF THE ANUS
these tu. are relatively rare■
Incidence comprising only 1-2% of all■
.cancers of the anus and large gut
In>80% of cases , human papilloma■
virus (HPV)may be detected
:The commonest symptoms are►
Bleeding , Pain , local growth of tumor
The lesion is often confused with■
hemorrhoids or other anal disorders
These tumors tend to become annular ,■
invade the sphincter , and spread upward
via the lymphatics into the perirectal
mesenteric lymph nodes
Occur regularly in AIDS patients■
Treatment depend on the tumor■
stage
The 5 year survival rate is 65% for■
localized tumor,and over 25% for
.metastatic disease
 Common Anorectal Condition

External hemorrhoids- 1
Anal Fissure- 2
Pruritus Ani- 3
Internal hemorrhoids- 4
Dentate line- 5
.Rectum- 6
Differential Diagnosis of
Rectal bleeding
 Causes of lower gastrointestinal bleeding
The sites shown are illustrative - many of the
lesions can be seen in. other parts of the colon
 Rectal polyp
It is like a tumor in
the rectum that
comes out at times
leading to fresh
bright red blood
after stools, which
are normal in
consistency and
non-painful
 DDx of Rectal Bleeding
Colorectal carcinoma-1
Polyps-2
Ischaemic colitis-3
Diverticular disease-4
Ulcerative colitis or Crohns colitis-5
Infectious proctitis-6
Hemorrhoids-7
Anal fissure-8
Solitary ulcer of the rectum-9
Rectal prolapse-10
 REMEMBER THAT
Hook worm is the most common cause of chronic-1
GI blood loss
Massive bleeding from lower GIT is rare , and-2
.usually due to Diverticular dis. or Isch. colitis
.Small bleeds from Piles occur very common-3
Procto-sigmoidoscopy should be done in all-4
patients with hematochezia(bleeding per rectum )
to exclude disease in the rectum or sigmoid colon
that could be mis-interpreted in the presence of
hemorrhoidal bleeding
Patients with iron deficiency anemia should- 5
undergo colonoscopy or barium enema to exclude
.disease proximal to the sigmoid colon
 ‫أشكر لكم حسن أستماعكم‬
‫والسلم عليكم ورحمة ال وبركاته‬
‫‪.‬‬