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1、Anal Diseases,Anatomy,Anorectal ring,Arterial supply of the rectum,Superior rectal arteryMiddle rectal arteryInferior rectal artery,Venous drainage of the rectum,Internal hemorrhoidal plexusExternal hemorrhoidal plexus,Reservoir Function,Mechanical adaptive compliance,lateral angulation of the valve
2、s of HoustonPhysiological contractile waves more frequent and higher amplitude in rectum than sigmoid,Sensory Components,Neuro pathwaysSympathetic+parasympathetic pathways to internal sphincter(hypogastric)Somatic to external sphincter(pudendal),Sphincter factors,Basal tonePressure zone anal canal 2
3、5120 mmHg rectum 5 20 mmHgContinuous tone of int.and ext.sphincter increases with increased abdominal pressure,Mechanism of Anal Continence,Structural considerationsAnorectal angle between rectum and anal canalFlap valve angle of the anterior rectal mucosa caused by puborectalis causes occlusionInte
4、rnal sphincter in continuous tonic state with external sphincter engaged during Vasalva,Anal Fissure,Ulcer in the lower portion of the anal canalAcute/chronic primary/secondarySx:anal pain,during and after BMs,Anal Fissure,Triade of anal fissureanal papilla hypertrophy fissure in anosentinel pile,Ac
5、ute Fissure,Treatmentinspection,usually increased anal tone can be appreciated on rectal exam if tolerated cleansing measures typically resolve in 6 weeks without surgical intervention,Chronic Fissure,sentinel tag,ulcer,hypertrophied anal papillaForm because of swelling,edema,and low grade inflammat
6、ion may go on to fibrosisExtends from the dentate line to the anal verge,Chronic Fissure,Teatmentnitroglycerin ointment 0.2%-0.4%BID Topical diltiazem(50%resolution at 6 weeks)Botulinum toxin A injection 42%recurrence at 42 months side effectsSurgery:lateral internal sphincterotomy,Lateral internal
7、sphincterotomy,Secondary anal fissure,Crohns diseaseNon-midline or abnormal appearing fissure should undergo margin biopsyAvoid surgery in neutropenic patients treat with perineal hygine and pain relief,Anorectal Abscess,Anorectal Abscess,Infection in one of the anal glandsMay be asymptomatic or cau
8、se severe throbbing pain that resembles a fissureAbscess should be drained when diagnosed,Anorectal Abscess,Sx:severe pain(aggravated by walking,straining)Swollen mass may be appreciated,Anorectal Abscess,Treatmentdrainage,avoid packing,no abscess typicallyCrohns disease oral metronidazole or ciprof
9、loxacin seems to have a mitigating effect,Fistula,Chronic form of perianal abscessEvaluation with anoscopy,endoanal ultrasound Classification,Fistula,intersphincteric,transsphincteric,suprasphincteric,extraspincteric,Goodsalls rule,Fistula,TreatmentUnroofing the fistula,eliminating the internal open
10、ing,and establishing adequate drainageOlder patients use loosely tied setons to allow for adequate drainage,Anal fistulotomy,Thread-drawing,Hemorrhoids,Hemorrhoids,Varices of hemorrhoidal plexusA-V communication in anal mucosa Vascular cushions thick submucosa with blood vessels,smooth muscle,elasti
11、c and connective tissue,Hemorrhoid Classification,External skin tagsExternal hemorrhoids(below the dentate line)Internal hemorrhoids,Internal hemorrhoids,BleedingProlapsePain usually associated with other anal disease,Internal hemorrhoids,TreatmentBulking agents for first and second degree hemorrhoi
12、dsSclerotherapy Infrared Photocoagulation Banding 2 3 ligations at 4 to 6 weekHemorrhoidectomyStapled Circular Hemorrhoidectomy for prolapsed hemorrhoids,Procedure for prolapsed hemorrhoids,Circumcise for hemorrhoids,Neoplasms of the Anal Canal,Squamous cell carcinomaBasaloid CarcinomaMucoepidermoid CarcinomasAdenocarcinomas,Thank you,
