Common Anorectal disorders & their management approach

1. ANORECTALANORECTAL
DISORDERSDISORDERS
Dr. Partha Das
MEM, PGY2
Fortis Hospital, Kolkata

2. COMING UPCOMING UP

3. HAEMORRHOIDSHAEMORRHOIDS
• Haemorrhoids (Greek: haima = blood, rhoos =
flowing) syn. piles (Latin: pila= a ball) are dilated
veins occurring in relation to the anus
(Ref : Bailey & Love’s Short Practice of Surgery, 26th
Ed.)

4. ANATOMICAL GLIMPSEANATOMICAL GLIMPSE
• External hemorrhoids →ectoderm & covered by
squamous epithelium of anal mucosa
• Internal hemorrhoids → embryonic endoderm &
lined with columnar epithelium of anal mucosa
• Internal & external hemorrhoids are divided by
‘’Dentate Line’’ (Pectinate line)
• Internal hemorrhoids drain through the superior
rectal vein → portal system. External hemorrhoids
drain through the inferior rectal vein →IVC
• Internal hemorrhoids are not supplied by somatic
sensory nerves and hence cannot cause pain
• external hemorrhoids are innervated by cutaneous
nerves that supply the perianal area

5. INTERNAL HAEMORRHOIDSINTERNAL HAEMORRHOIDS
• More common than external haemorrhoids
• Dilatation of the internal venous plexus with an
enlarged displaced anal cushion
• From superior hemorrhoidal plexus

6. ETIOLOGYETIOLOGY
• Hereditary
• Anatomical (absence of valves in hemorrhoidal
veins/ pelvic floor defect)
• Exacerbating factors (straining/obesity/chronic
cough)
• ↑ intra abdominal pressure (ascites/intra
abdominal mass/ pregnancy)

7. PATHOPHYSIOLOGYPATHOPHYSIOLOGY

8. Contd…Contd…
• Engorgement of normal fibrovascular lining of
anal canal
↓
• Prolapse of internal hemorrhoids tissue
through anal canal
↓
• Thinning of the friable overlying mucosa
↓
• Subsequent bleeding occurs
(*Internal hemorrhoids course along terminal branches
of Superior rectal artery & are located at the 2-, 5-, and
9-o'clock positions when the patient is viewed prone)

9. GRADINGGRADING
(Ref : Sabiston Textbook of Surgery, 18th
Ed)
GRADE SYMPTOMS & SIGNS
First degree Bleeding; no prolapse
Second degree Prolapse with spontaneous
reduction, bleeding, seepage
Third degree Prolapse requiring digital
reduction
Bleeding, seepage
Fourth degree Prolapsed, can not be reduced,
strangulated

10. CLINICAL FEATURESCLINICAL FEATURES
• Painless bright-red rectal bleeding with
defecation
• With ↑ in size, hemorrhoids may prolapse
• Mucoid discharge
• Pruritus ani
• Pain – if complications supervene
(strangulation, abscess etc)

11. EXTERNAL HAEMORRHOIDSEXTERNAL HAEMORRHOIDS
• Arises from inferior hemorrhoidal plexus
• occurs in the pen-anal s.c. connective tissue,
superficial to the Corrugator Cutis ani muscle
• Tender swelling which resembles a semi ripe
blackcurrant
• Untreated it may resolve, suppurate, get
fibrosed & cause bleeding.
• A thrombosed external haemorrhoid is
commonly termed a perianal hematoma

12. COMPLICATIONSCOMPLICATIONS
• Profuse hemorrhage leading to Anaemia
• Strangulation - prolapsed pile is gripped by
external sphincter → severe pain
• Thrombosis
• Ulceration of the exposed mucous membrane
• Gangrene - occurs when strangulation is tight
to constrict the arterial supply of the
haemorrhoid
• Fibrosis
• Suppuration - as a result of infection of a
thrombosed haemorrhoid
• Portal pyaemia & Liver Abscess – Rare
(Ref : Bailey & Love’s Short Practice of Surgery, 26th
Ed.)

13. DIFFERENTIALSDIFFERENTIALS
• Anorectal fissures
• Anorectal fistulae
• Rectal abscess
• Colorectal Ca
• Rectal varices (d/t Portal HTN)
• Inflammatory bowel disease
• Diverticular disease
• Angiodysplasia
• Anal warts
• Anal skin tags
• Rectal prolapse
• Rectal polyps
• Enlarged anal papillae

14. MANAGEMENTMANAGEMENT
• General measures & prevention
• Better local hygiene
• Avoiding excessive straining
• Better dietary habits (↑fiber & fluids)
• Weight reduction if obese
• Avoiding excessive wiping after defecation (to
↓ local irritation)
• Warm sitz baths with Betadine lotion (↓
sphincter pressures) for at least 15 min 3
times/day

15. Contd…Contd…
• Care in ER
• Acutely thrombosed external hemorrhoids may
be safely excised in ER in patients who
present within 48-72 hours of symptom onset.
• Infiltration of a local anesthetic containing
epinephrine
↓
• elliptical incision & excision of the thrombosed
hemorrhoid, its accompanying vein & overlying
skin
↓
• A pressure dressing is applied → wound is left
to heal by secondary intention

16. Contd…Contd…
• Pharmacotherapy
• Topical analgesic & antibacterial ointments
• Topical lidocaine-mild steroid combination
ointments
• Mild astringent (Hamamelis water to ↓itching)
• Bulk laxatives & stool softeners
• Antidiarrheal agents (Metronidazole)
• Oral Calcium Dobesilate 500mg BD
(Angioprotective action - ↓ bleeding per
rectum)

17. Contd…Contd…
• Non surgical procedures
• Lord’s anal stretch (rarely done)
• Rubber band ligation (grades II and grade III)
• Infrared coagulation (for grade I and II)
• Bipolar electrocautery (for lower-grade
hemorrhoids)
• ScleroRx & CryoRx (S/E – abscess, urinary
retention)
• Laser therapy and Radiowave ablation (for
prolapsing hemorrhoids)
(Ref : http://emedicine.medscape.com/article/775407-overview)

18. • Contraindications for non surgical
techniques
• Immunodeficiency disorders
• Coagulopathy
• Irritable bowel disease
• Pregnancy
• Immediate post partum period
• Rectal wall prolapse
• Large anorectal fissure or infection
• Tumour
(Ref : http://emedicine.medscape.com/article/775407-overview)

19. Contd…Contd…
• Surgical Intervention
• Surgical hemorrhoidectomy
– i) Milligan-Morgan Open Hemorrhoidectomy
– ii) Ferguson’s Closed Hemorrhoidectomy
• Complications
– Post op pain
– Urinary retention
– Anal stenosis
• Stapled hemorrhoid surgery
• Doppler-guided transanal hemorrhoidal dearterialization
• Hemorrhoidal artery ligation (HAL) & rectoanal repair
(RAR) (HAL with mucopexy) - minimally invasive
alternative to conventional hemorrhoidectomy

20. ANAL FISSUREANAL FISSURE
• An anal fissure is a linear ulcer of the lower
half of the anal canal, usually located in the
posterior commissure in the midline
(Ref : Sabiston Textbook of Surgery, 18th
Ed)

21. SALIENT FEATURESSALIENT FEATURES
• M/c location – posterior midline
• Other associated conditions: -
– Sentinel pile or tag externally
– Enlarged anal papilla internally
– Hidradenitis suppurativa
– STDs
– IBD
• With defecation, the ulcer is stretched causing
severe pain & mild bleeding

22. ETIOPATHOGENESISETIOPATHOGENESIS
• Trauma from passage of hard stools
• Low-fiber diets
• Prior anal surgery
• Hypertonicity &hypertrophy of the internal anal
sphincter
• Posterior anal commissure is the most poorly
perfused part of the anal canal.
↓
• In patients with hypertrophied internal anal
sphincters, this delicate blood supply is further
compromised
(Ref : Sabiston Textbook of Surgery, 18th
Ed)

23. MANAGEMENTMANAGEMENT
• Warm Sitz baths
• Hydrocortisone & lidocaine L/A for acute fissures
• Stool softeners & fiber supplements
• Topical Nitroglycerin (local application →NO
donor→ resting anal pressure ↓ → anodermal
blood flow ↑)
• Topical application of 2% Diltiazem (fewer S/E)
• Botulinum toxin (Injected into ext & int sphincters
→striated muscle denervation →muscle paralysis
& relaxation)
• Lateral internal Sphincterotomy (Closed/Open
technique)
(Ref : Sabiston Textbook of Surgery, 18th
Ed)

24. RECTAL FOREIGN BODIESRECTAL FOREIGN BODIES
• It’s a matter of humour for
population in general but not for
doctors!!
• Presentation is almost always
delayed because of
embarrassment.

25. ETIOLOGYETIOLOGY
• As a result of erotic activity (Sex toys, bottles,
vegetables)
• Attempt to conceal drug packets/ weapons
• As a result of assault (Child abuse)
• Older patients → constipated→ FB introduced
for manual disimpaction→ FB lost during this
activity
• FB may be ingested (fish or chicken bones,
toothpick etc)→ navigates the entire GI tract→
gets impacted in rectum

26. CLASSIFICATIONCLASSIFICATION

27. CLINICAL FEATURESCLINICAL FEATURES
• Fever
• Leucocytosis
• Abdominal pain
• Rectal bleeding
• Rectal tears & pain
• Peritoneal signs (S/o Perforation)
– Severe abdominal pain
– Vomiting
– Guarding/Rigidity
– Rebound tenderness

28. WORK UPWORK UP
• Lab studies – Do not add much useful
information
• Hematocrit (useful if bleeding is present)
• ↑WBC count (indicates concomitant infection)
• X ray of abdomen – Radio-opaque shadows
indicate :-
• Position, shape, size & no. of FB
• Possible presence of free air (S/o Perforation)
• * Perforation of rectum :-
– Below peritoneal reflection→ extra peritoneal air along
psoas muscle on flat X ray
– Above peritoneal reflection→ intra peritoneal free air ↓
diaphragm in upright CXR
Proctoscopy
(Ref : Tintinalli’s Emergency Medicine, 6th
Ed)

29. Contd…Contd…
(Rectal FB : Body packing)
(Ref : http://radiopaedia.org/images/526)

30. MANAGEMENTMANAGEMENT
• Most important→ to respect privacy of patients
• Sphincter relaxation→infiltrative L/A & i/v sedation
for proper relaxation
• Manual extraction or with use of forceps/retractors
• Passing a Foley’s cath distal to object & inflating
the balloon
• Repair of anal lacerations
• Urgent surgery/ Laparotomy (for large deeply
impacted FBs/signs of perforation)
• Fluid resuscitation & broad spectrum ABx (in ↓BP
d/t sepsis or hemorrhage.)
• Psychiatry consultation & counseling
(Ref : Tintinalli’s Emergency Medicine, 6th
Ed & www.medscape.com)

31. REFERENCESREFERENCES
• Bailey & Love’s Short Practice of Surgery, 26th
Ed
• Sabiston Textbook of Surgery, 18th
Ed
• Tintinalli’s Emergency Medicine, 6th
Ed
• www.medscape.com
• Indian Journal of Clinical Practice, Vol. 25, No. 6,
November 2014, Page 577
• Coskun et al. World Journal of Emergency
Surgery 2013, 8:11
(http://www.wjes.org/content/8/1/11)