ANORECTUM (HEMORRHOIDS,ANAL FISSURES,ANORECTAL ABSCESS)

HEMORRHOIDS   Etiology   anal cushions, vascular and connective tissue complexes, become engorged forming hemorrhoids proposed ...

HEMORRHOIDS

 
Etiology

 

1. anal cushions, vascular and connective tissue complexes, become engorged forming hemorrhoids proposed
2. causal factors
• increased intra-abdominal pressure
• chronic constipation
• pregnancy
• obesity    

Classification and Management

 

Internal hemorrhoids

1. plexus of superior rectal (hemorrhoid) veins ----> portal circulation
2. engorged vascular cushions above dentate line usually seen at 3, 7, 11 oíclock positions ---> when patient in lithotomy position
3. Patient may complain painless rectal bleeding, anemia, prolapse, mucus discharge, pruritis, burning pain
4. 1st degree: bleed but do not prolapse through the anus
   • high fibre/bulk diet, sitz baths,
   • steroid cream,
   • rubber band ligation,
   • sclerotherapy,
   • photocoagulation
5. 2nd degree: bleed but prolapse with straining, spontaneous reduction
• rubber band ligation,
• photocoagulation
6. 3rd degree: bleed and prolapse requiring manual reduction
• same as 2nd degree,
• may require closed hemorroidectomy
7. 4th degree: permanently prolapsed, cannot be manually reduced, bleeding
• closed hemorroidectomy

External hemorrhoids

 

1. plexus of inferior rectal (hemorrhoid veins) ---> systemic circulation
2. dilated venules below dentate line or perianal skin tags usually asymptomatic unless thrombosed, in which case they are very painful
3. usually present with pain after bowel movement
• medical therapy: dietary fiber, stool softeners, avoid prolonged straining
• thrombosed hemorrhoids resolve within 2 weeks
4. hemorrhoidectomy when patient presents within the first 48 hours of thrombosis, otherwise treat conservatively
   

ANAL FISSURES

 

1. tear of anal canal sensitive squamous epithelium below dentate line
2. 90% posterior midline, 10% anterior midline
3. if off midline: IBD, STDs, TB, leukemia or anal carcinoma
4. Etiology
• large, hard stools and irritant diarrheal stools
• tightening of anal canal secondary to nervousness/pain
• others: habitual use of carthartics, childbirth
  

Acute Fissure

 

• very painful bright red bleeding especially after bowel movement
• treatment is conservative: stool softeners, sitz baths
  

Chronic Fissure

 

1. triad: fissure, sentinel skin tags, hypertrophied papillae
2. treatment = surgery
• objective is to relieve sphincter spasm ----> increases blood flow and promotes healing
• lateral subcutaneous internal sphincterotomy at 3 o’clock position

 

ANORECTAL ABSCESS

 

1. bacterial infection of intersphincteric space starting from anal glands that empty into anal crypts
2. E. Coli, Proteus, Streptococci, Staphylococci, Bacteriodes, anaerobes
3. abscess can spread vertically downward (perianal), vertically upward (supralevator) or horizontally (ischiorectal)
4. treatment: incision and drainage are curative in 50% of cases, 50% develop anorectal fistulas
   

Perianal Abscess 

 

1. unremmiting pain
2. indurated swelling

Ischiorectal Abscess 

 

1. abscess in fatty fossa, can spread readily: necrotizing fasciitis, Fournier's gangrene 
2. pain, fever and leukocytosis prior to red, fluctuant mass

Supralevator Abscess

 

1. difficult to diagnose, rectal mass
2. swelling detectable with exam under anesthesia