Proctology

Proctology

FISSURE-IN-ANO

A traumatically induced longitudinal tear in the epitheliumo of the distal anal canal. Extends from the anal verge cephaled up to the dentate line

Epidemiology

Posterior >90%, Anterior >10% (10% of female fissures, 1% of male fissures)

Acute <6 weeks

Chronic > 6 weeks

Features

• Sentinel pile
• Midline fissure
• Hypertrophied papilla

Aetiology- risk factor

• Hard stool traumatises the skin at defecation
• EAS elliptical, least support in the A-P plane
• Raised MARP in those with fissures
• Suggests increased IAS pressure contributes to chronicity
• Blood vessels traverse the IAS
• Therefore raised sphincter pressure will hinder vascularity
• Vascularity improves post sphincterotomy
• MARP decreases post sphincterotomy
• Crohn's

Presentation

• Anal pain with stool
• ‘Knife-like’, ‘passing glass’
• Persists post defecation
• Relieved by a sitz bath
• Pruritis, prolapse, swelling
• Bright red rectal bleeding

Diagnosis

History

• of painful defecation
• Pain post defecation
• Blood on toilet paper

On Examination

• Spasm anus
• Sentinel pile
• View the fissure with anal effacement

Management

Aim

Correct the precipitating factor – HFD

Topical treatment – GTN, Diltiazem, Botulin Toxin

Only if medical treatment fails should surgery be considered

GTN

• The original topical therapy
• Good healing
• rate 25% relapse
• Side effect profile poor: 24-75% patient described headache

Diltiazem

• Topically twice daily for 4weeks
• Heals 70-90% of fissure
• Very few side effects

Botulin toxin

• Correct the precipitating factor – HFD
• Topical treatment – GTN, Diltiazem, Botulin Toxin
• Only if medical treatment fails should surgery be considered
• The original topical therapy
• Good healing rate
• 25% relapsed
• Side effect profile poor
• 24-75% patients described headache

Lateral internal Sphincterotomy

Indication

Chronic anal fissure which has failed to respond to medical management

Rarely in acute anal fissure

Contraindications

poor sphincter tone

previous obstetric injury

history of traumatic childbirth

Procedure

Jack-knife position

Can be done in OPD

Open or closed technique

Division of IAS to the level of the dentate ONLY

Fissurectomy

Complications

Infection

Fissure-fistula

FAECAL INCONTINENCE

• 1-60% immediately post op
• Mainly females
• Self limiting generally
• Overall <1%
• IF it is done CORRECTLY

19% of PG and 29% of MP have EAS injury

Up to 30% will develop incontinence post ILS

Other options!

Fissurectomy

Fissurectomy and advancement flap

Management of Faecal incontinence

surgeon

continence nurse/stoma therapist

radiologist

electro physiologist

physiotherapist

dietician

Sacral nerve stimulation

Neuromodulation

S3 or S4 nerve root

Trial possible

Approx 70% good response

permanent implant of pacemaker like device

PILONIDAL SINUS

Hair-containing sinus or abscess that usually involves the skin and adjacent tissues in yhe intergluteal region

Epidemiology

80% in males

15-24 years old

25 per 100,000

Asymptomatic pits

Symptomatic

• Abscess
• Chronic drainage

Aetiology- described by Karyadakis

3 Factors

• The invander- the loose hair
• the force causing insertion
• The vulnerability of the skin

Presentation

• Pain, swellimg and drainage wwhen the sinus become infected

             

Treatment Options

1.  Abscess drainage alone

• Adequate drainage
• Elliptical incision in the midline
• Often definitive in patients over 30 years old
• Up to 50% require no further treatment
• Drain all PN abscesses
• If sinus persists after 6 months excise PNS

2. Fistulotomy and Curettage

• Unroofing all sinuses and allowing them heal by 20 intention
• Easy to perform
• Prolonged wound care required
• Jack-knife position
• Aggressive skin shaving
• Identify sinuses with a probe
• Unroof all
• Curette the base
• Lightly pack gauze into the wound
• Patient education re shaving skin 4 cm around the wound
• 4 studies including 273 patients. Follow up on 230
• Time to healing was 27 days to 6 weeks
• Recurrence rate 1-19%

Marsupialisation

Bascom’s operation

Excision and primary closure

3.  Flap procedures

• Z plasty

• 
  

• 
  • Obliterates the natal cleft
  • Recurrence rate 0-2%
  • DC form hospital within 24 hrs
  • Return to work within 2 weeks
• V-Y advancement flap

• 
  
  
• 
  • Unilateral or bilateral
  • Obliterates the natal cleft
  • Tension free
  • Eliminate dead space
• Rhomboid flap
• 
  
  
• 
  
• Gluteus maximus myocutaneous flap
• 
  
  
• 
  • Covers large wounds
  • Prolonged hospitalisation
  • Morbidity
  • Reported use when all other methods fail
  • Not for routine use

FISTULA IN ANO

the occurance of malignant lesions in the mucosa of the colon or rectum

Epidemiology

As described cryptogladular abscess

Trauma

Crohns disease

Tuberculosis

Cancer

Radiation

Aetiology

Cryptoglandular

Intersphincteric abscess

Underlying disease

                            - Crohn’s              - Aids

                            - TB              - Presacral cyst

                            - Lymphoma              - Cancer

Classification

1.Intersphinteric (70%) ;The fistula tract is confined to the intersphincteric plane

2.Transsphinteric (25%); the fistula connects the intersphinteric palne with the ischiorectal fossa by perforating the external sphincter

3.Suprasphinteric (4%); Similar to transsphinteric but the track loops over the external and perforates levator ani

4.Extrasphincteric (1%);The track passes from the rectum to perineal skin completely external to the sphincteric complex

Goodalls Rule

• Describes the relationship between primary and secondary orifices
• The rule predicts that if a line is drawn transversely across the anus an external opening will lead to a straight radial tract whereas an external opening that lies posterior to the line will lead to a curved tract and an internal opening in the posterior midline
• The Long anterior fissure is the exception to this rule.

Investigation

1.Endoanal Ultrasound demarcates sphincter  involvement

2. MRI fistulogram gold standard for  anatomic fistula identification

Surgery

Under GA –Palpation for induration

-Proctoscopy

- Gentle probing of the fistula tract

- If internal opening not identified by probing Inject hydrogen peroxide through  stoke on trent duct to visualise Internal opening                                                                                         

Options

• Fistulotomy
• Seton
• Flap advancement
• Collagen Plug

HAEMORRHOID

a submucosal swelling in the anal canal arising from the anal cushions and consisting of a dilated venous plexus, a small artery and areolar tissu, internal haemorrhoids only involve tissues of upper anal canal; external haemorrhoids involves tissue of lower canal.

Found at the 3, 7 and 11 o'clock position

Aetiology

Prolonged increased pelvic pressure

• cosntipation
• pregnancy
• urinary outflow obstruction

Venous obstruction

• Fail to empty rapidly during defeacation
• abnormally mobile
• trapped by a tight anal sphinter

Prolapse of vascular cushions

Dietary factors

Anal tone

Defaection Pattern

Presentation

Bleeding

Prolapse and discomfort

Pain

Discharge

Thrombosis

Anaemia

Diagnosis

History

Examination (Eversion of peri-anal skin)

Proctoscopy

Left Colonoscopy

Staging

Degree	Symptoms	Treatments
First	Bleeding	Diet, injection
Second	Prolapse during straining, reduces readily, Pruritis	Injection, band ligation
Third	Prolapse (manual reduction), discomfort	Band ligation, haemorrhoidectomy
Fourth	Thrombosis, pain,fever	urgent/elective haemorrhoidectomy

Management

Advice, defeacation habits, diet

Injection Sclerotherapy

3 mls of phenol with araicis oil

Mucosa- elevate  but  not  blanch

Avoid  anterior  injection

More  than  one  session  often  required

Rubber Band Ligation

>1  application  possible

Forceps  should  be  painless !

Immediate  pain  -  remove !

Avoid  in  immunocompromised

More  effective  than  sclerotherapy  in  comparative  trials.

Meta-analysis  8060 patients  -  5.8 %  pain

                                                          -  1.7 %  haemorrhage

                                                          -  2.8 %  failure  /  recurrence

Operative Treatment

open procedures

Closed procedures

Stapled anoplasty

Complications

Thrombosed Pile’

• Perianal haematoma
• Cannot (and should not) be reduced
• Starts as itchy discomfort
• Pain becomes progressive
• Treatment is excision if seen early, otherwise will settle

External tags

• Common
• Difficult to get good result
• Symptoms- Hygiene, Puritis, Aesthetic

Pruritis Ani

• Common
• Diet- Coffee, Alcohol, Chocolate
• Hygiene
• Fungal infection
• Skin condition