Transcript cursul 12 Hemoro+Anal+Perianal+canal anal

Haemorrhoids
Essentials of diagnosis
Rectal bleeding, protrusion, discomfort
Mucoid discharge from rectum
Secondary anaemia
Characteristic findings on anal
inspection and anuscopic examination
THE PROBLEM
Nobody likes them:
patients and doctors
Very frequent
Major discomfort
Treated often by
non-specialists
Well treated=
good results
Sensitive
area
DEFINITION
Normal structures of the rectal wall which are
displaced from the original position
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Normal histological structures
Plenty vascularization: both arterial (inferior
haemorrhoidal artery) and venous lakes which
may be distended.
Chrinic constipation + straining on defecation +
increased anal tonus – favor the development of
haemorrhoids.
Symptomatic
classification
Grade 1 – bleeding
Grade 2 – prolaps with spontaneous
reduction
Grade 3 – prolaps that needs digital
replacement
Grade 4 – Prolaps - permanent
TRATAMENT – depending on symptoms
Anatomic classification
Symptoms
Painless bleeding
Pruritus
Prolaps
Pain (asociated with a complication –
thrombosis or inflamation)
Incontinence
BLEDDING PER RECTUM
How to evaluate!!!
Small drops of blood on toilet paper

Clinical examination + rectal + rectoscopy
Blood dropping in the toilet
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Rigid recto-sygnoidoscopy
Blood mixed with feces
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Rigid recto-sygnoidoscopy + barium enema OR
colonoscopy = complete examination of the colon
Dark blood
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Complet examination of the colon
Massive OR Chronic
May be massive and presents as an
emergency
May be a cause of chronic anaemia
May explain
Severe iron deficiency anaemia
 Ischaemic cardiac disease due to low
levels of oxygen transporter
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NEVER
NEVER treat haemorrhoidal disease
without clinical and digital examination
of the rectum
MALPRAXIS = patients life and your
money
PRURITUS ANI
Frequently associated with haemorrhoids
Minute incontinence with local irritation of the
skin
 Aggressive local cleaning may produce small
lesions that will generate pruritus
 Tags
 Local edema
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PAIN
External thrombosed haemorrhoids

Round blue lesions (perianal haematoma)
with significant edema and very tender
Internal thrombosed haemorrhoids
Pain is less severe
 Major pain in cases of strangulated prolaps
of haemorrhoids

EXAMINATION
Speaking with the patient will create
trust
Offer an intimate room

RECTAL EXAMINATION
Blind – use a hydro soluble gel
Forts evaluate visually the perianal
region
Evaluate the tonicity of the sphincter in
non contracting status and during
contraction
Prostate
Content
RECTOSCOPY
ANUSCOPY
SYGMOIDOSCOPY
RECTOSCOPY +
ANUSCOPY
Masses that
prolaps in the
tube of the
scope
Stigmata of
recent bleeding
WHY COMPULSORY TO
EVALUATE
Colonic cancer is
frequently missed
due to obvious
haemorrhoidal
disease
Main diagnosis is
delayed for a long
time – too late
CONSERVATIV
TRATAMENT
Bleeding
Dietary suplements with fibers (larger
volume + softer)
Increase vascular tonus
Ginko Biloba
 Flavonoids (Detralex)

CONSERVATIV
TRATAMENT
PRURITUS
Hot bath – decreasing muscular tonus
Fibers in food
Analgetic creams
Corticoids locally (supositories or
cream) but no more then 7 days
Changed local hygiene
CONSERVATIV
TRATAMENT
THROMBOSIS OF HAEMORRHOIDS
Surgical thrombectomy – first 48 hours
Analgetics
Dietary changes
Hot bath
Surgical treatment
1 – Milligan - Morgan
Surgical treatment
2 – Ferguson
Surgical treatment
3 – Stappler haemorrhoiedctomy
NEW TECHNIQUES
BANDING
Principles:
Elastic ligatures on the base of
haemorrhoid followed by necrosis
 Detachment of necrotic area
 Scar formation + sclerosis will fix the
mucosa
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SCLEROTHERAPY
Irritative substances
(Almond oil +
phenol)
Slerosis + fixation of
mucosa
Injection only
around vessels
ANAL DILATION
Hypertony is a major cause of pain
Unde rgeneral anaesthesia
Make banding easier and better
Decreased the tonus of the sphincter –
mechanism of hemorrhoid formation
Not in cases with low tonus
FOTOCOAGULATION
Infrared radiation
directly over the
hemorrhoid
Therncauterisation
followed by sclerosis
In stages
CRIOCOAGULATION and
ELECTROCOAGULATION
Criotherapt forceps – rapid cooling at 36 degree
Similar effects with infrared
thermocoagulation
Lesions will shrink
More efficient for large hemorrhoids
CO2 LASER
Hemorrhoidectomy by vaporisation of
tissue
Similar with surgical excision
Very expensive and difficult to use
Harmonic knife
Ultrasonic energy
Very little effects on the tissue around
the area treated
No smoke, low temperatures (50-100
degrees)
Seals vessels and coagulates proteins
Harmonic knife
No burned tissue
(doesn’t coagulate via
dessictaion)
Coagulates even large
vessels
Low chances for
postoperative bleeding
Ligation of
haemorrhoidal artery
HAL
New technoque
Ligation of feeding artery
Good results
COMPLICATIONS OF
ALL METHODS
Stenosis
Tags
Recurencies
Fissure
Incontinence
Impactation with feces
Postop bleeding
RESULTS
Very good
Dependeing on the tpe of hemorrhoids
and clnical signs
Rational choice of therapy
Better in the hands of a proffesional
FISSURA IN ANO
ANAL FISSURE
General considerations
Denuded epithelium of the anal canal
overlying the internal sphincter
Painful – highly sensitive area
Typically single ulcerations
Hypertrophic papilla – chronic
inflammation
Sentinel pile
Diagnosis
3 ELEMENTS
Ulcer
 Hypertrophic pappila
 Sentinel tag

Clinical findings
Symptoms and signs:
Painful bowel movement associated with
bright red bleeding
 Pain severe: after movement and
sensation is described like burning
 Constipation

Clinical examination
With anaesthesia
Rectal:
Tag
 Ulcer – in the middle
 Pappila
 Increased tonus
 Sigmoidoscopy should be deffered

Differential diagnosis
Other ulcers:
Syphilis
 Carcinoma
 TBC
 Granulomatous enetritis with ulcers

NOT TYPICAL

Biopsy
Association with haemorrhoids
TREATMENT
Medical:
Softening of the stool
 Topical cream with myorelaxant
 Hot bath
 Flavonoids

Surgical:
Lateral internal shpyncterotomy
 Anal dilation
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PROGNOSIS
Very good if good care
Tend to become chronic
The do not become malignant
ANORECTAL ABSCESS
ESSENTIALS OF
DIAGNOSIS
Persistent throbbing rectal pain
External evidence of absecss
Systemic manifestations of infection
General considerations
Invasion of pararectal spaces by
pathogenic microorganisms (mixed
infection + frequent anaerobs)
Infection starts from an infected cript
Classification is anatomical according to
the spaces invaded
Classification
Perianal – bellow levator ani
Ischiorectal – ischiorectal fossa
Retrorectal
Submucous
Marginal – in the anal canal
beneath the anoderm
Pelvirectal
Intermuscular
Clinical Findings
The more superficial, the
more painful
PAIN – related to sitting and
walking
Infection: swelling, redness,
induration, tenderness
Deep abscess – limited
local signs + sepsis
Complications
Spreading to adjacent spaces
Pelvic gangrene or necrotizing fasciitis
when anaerobic infections spread
without concern for anatomic bariers
Fistula formation
TREATMENT
SURGICAL
Incision and drainage
 Do not wait for the abscess to point
externally
 Fistulotomy may come in discussion if a
fistula is found (caution for the quality of
the remnant sphincter)
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ANORECTAL FISTULA
Essentials of diagnosis
Chronic purulent discharge
TRACT: palpable or probed will lead in
the rectum
General considerations
At least 2 openings
Most fistulas
originate in the anal
cript
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Subcutaneous
Submucoasal
Intramuscular
Submuscular
Anatomical
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Anterior
Posterior
Single/complex
Horseshoe
Clinical
Findings
Symptoms and signs
Purulent drainage and discharge
 Palpation - cordlike tract in relation with the
spincter
 Probe

Rectal examination + rectoscopy – the
internal opening
Exploration
Contrast fistulography
MRI
Anatomy of the fistula for surgical excision
 Mostly in complex fistulas
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Differential diagnosis
Hidradenitis suppurativa
Pilonidal sinus
Granulomatous disease – Crohn
Infected lesions (comedomes, sebaceous
cyst, foliculitis, bartholinitis)
Retrorectal dermooid tumor
Coloperineal fistula
Postraumatic sinuses or foreign body
Etc.
Complications
Recurrent abscess formation
Generalized sepsis
Carcinoma in a chronic untreated fistula
is possible
Treatment
SURGICAL
Primary opening must be found end
excised
 Complete identification of the tract
 The tract must be unroofed on the entire
length – open wound
 Careful construction of the wound to favor
healing
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Operations for fistula
Pilonidal disease
Essentials in diagnosis
Abscess or chronic discharges from a
sinus in the sacrococcigeal area
Pain, tenderness, induration
General considerations
Drainig sinus or abscess
Underlying cyst containg granulomatous
inflammation, fibrosis + tufts of hair
Congenital vs aquired
CAUSE: infection + irritation and
trapping hair in deep tissue of the area
Clinical Findings
Asymptomatic until becomes infected
Acute suppuration in sacrococcigean
area
If drained spontaneously – sinus with
intermittent discharge
Probe may pass in the sinus – in to the
cyst
Complications
Infection + multiple tracts
Sepsis
Malignant degeneration - rarely
Treatment
Acute abscess:

Drainage
Chronic disease:
Excision of all damaged tissue
 Cystotomy to excision
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Malignant tumors of
the anal canal
Epidermoid carcinoma
75% of all malignancies of the area
Early: verucous, nodular lesion
 Late: ulcerated, indurated, nodular nmass
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Palpable inguinal nodes
May invade the rectum: false imprssion
of rectal carcinoma
Lymphatic spread: like rectal + inguinal
nodes
Treatment
External radiation + concomitant
chemotherapy
Radical surgery in case of failure
Malignant melanoma
Horrible prognosis
Dark mass protruding from the anus
50% pigmented
Lymph node MTS early
Treatment - not clear advantage of any
alternative
Bowen’s disease
carcinoma in situ
Like all other places of skin
Plaque-like eczematoid lesion + pruritus
Biopsy-carcioma in situ +
hyperkeratosis and giant cells
Therapy: local excision with safety
margins
Basal cell carcinoma
Ulcerating tumor (uncommon)
“Rodent ulcer” like every other place of
skin exposed
Doesn’t spread distantly
Local excision
Paget’s disease
Rare condition
Pale plaquelike condition with induration
+ nodular mass (not always)
Nodular mass= coloid carcinoma from
glands or other skin appendages
Local excision (without mass)
Radical surgery + chemo + RT for
coloid carcinoma