ANAL & PERIANAL

DISORDERS
 RECTUM
• Average length of the human rectum may range between 10-
15cm
• It becomes larger near the anus where it forms the rectal ampulla
• The key roles is to act as a temporary storehouse for feces
• The expansion of rectal walls causes the stretch receptors within
the walls to stimulate the urge to defecate
ANATOMY OF ANAL CANAL
• At the anal verge outside the anal canal, there is normal
skin composed of stratified squamous epithelium with
skin appendages—sweat glands, hair follicles and
sebaceous glands
• The anal canal proper is about 4 cm long, extending from
the lower to the upper border of the internal sphincter. It
is divided into upper and lower halves by the dentate
(pectinate) line.
• Above Columnar epithelium
• Below  Squamous epithelium (anoderm)
• Transitional zone  Cuboidal epithelium
• Bottom of anal column of Morgagni are anal sinuses or
crypts, into which open the anal glands and anal papillae.
• The anorectal ring is situated about 5cm from the anus. It
formed by the internal sphincter, deep part of external
spinchter and the puborectalis muscle
ANATOMY
• The lowest or distal zone lies between the squamous–mucocutaneous junction and the level of the anal valves
at the dentate (pectinate) line. This is lined by non-keratinising squamous epithelium without skin appendages
or glands; the epithelium contains some melanocytes. This area is exquisitely sensitive, for example to injection

• The anal transitional zone (ATZ). This lies between the zone of squamous epithelium below and the columnar
mucosal zone above, and extends a distance varying between 0.3 and 2 cm. It consists of transitional epithelium
resembling urothelium, 4–9 cell layers thick. Anal glands are present in the submucosa but there is minimal
mucin production. A unique type of anal carcinoma develops from it with a viral aetiology

• The upper part of the anal canal is lined by rectal mucosa. On proctoscopic inspection, it is a dark reddish-blue
where it overlies the submucosal venous plexus, becoming the typical pink of colorectal mucosa more proximally.
This area of mucosa is relatively insensitive
PECTINATE LINE
 ANAL SPHINCTER
The anal sphincter mechanism has three constituents:

the internal sphincter (involuntary) , the external sphincter (voluntary)

and the puborectalis muscle.

• The internal sphincter represents a downward but thickened

continuation of the rectal wall musculature. (autonomic nervous
system)

• The encircling external sphincter and the puborectalis sling (part of

levator ani) arise from the pelvic floor. (internal pudendal nerve S2-S4)

• Continence is maintained principally by the anal sphincters squeezing

the three anal cushions together to occlude the lumen. Continence is
assisted by the rectum forming a compliant reservoir to accumulate
faeces.
 BLOOD SUPPLY
• Arterial supply:
• Upper half  Superior rectal artery
• Lower half  Inferior rectal artery

• Venous drainage:
• Upper half  Superior rectal vein  Portal system
• Lower half  Inferior rectal vein  Systemic
circulation
Hemorrhoids
• swollen blood vessels in the lower rectum.
• Most common cause of anal pathology.
• Internal and External

• Anal Cushion
• Highly vascular tissues in anal canal in submucosal space
• 3 Main cushions
• Left lateral (3 o’clock)
• Right posterior (7 o’clock)
• Right anterior (11 o’clock)
• When prominent, veins in this cushions form the internal hemorrhoids
Causes
• Constipation
• Prolonged straining
• Irregular bowel habits
• Diarrhea
• Aging
• Pregnancy
• Interior sphincter abnormalities
• Portal hypertension & anorectal varices
Classification
• Classified based on anatomical origin and by position relative to
Dentate line.

• Internal hemorrhoids
• External hemorrhoids
• Mixed hemorrhoids (both)
 EXTERNAL INTERNAL
HEMORRHOID HEMORRHOID
Below dentate line Above dentate line

Varicosities of veins draining Varicosities of veins draining

inferior rectal artery superior rectal artery

Lined by Lined by
squamous epithelium columnar epithelium

Painful Pain insensitive

(somatically innervated) (autonomic nervous system )

Prone to thrombosis if vein

May prolapse outside anal canal
ruptures
(prolapsed hemorrhoid)
(Thrombosed pile)
Classification of Internal Hemorrhoids
Complications
• Strangulation or thrombosis
• Ulceration
• Gangrene
• Fibrosis
Treatment
1. Conservative
• Warm baths
• High fiber diet
2. Non-surgical
• Rubber band ligation (grade 2 & 3)
3. Surgical
• Excision
• Hemorrhoidectomy
• Procedure for Prolapsing Hemorrhoids (PPH) (staplers)
ANAL FISSURE
A longitudinal
split(ulcer) in the
anoderm of distal
anal canal, which
extend from the anal
verge proximally
towards, but not
beyond, the dentate
line.
AETIOLOGY

ACUTE CHRONIC
• Trauma • Repeated trauma
- constipation and usually heals • Anal hypertonicity
quickly. • Vascular insufficiency
- Repeated diarrhea. - Tearing-pain-spasm-more
tearing. Become fibrous then
chronic ulcer.
CLINICAL FEATURES:
• Severe anal pain associated with defecation.
• Bright red bleeding
• Mucous discharge
• Constipation
EXAMINATION:
• Split in anal skin.
• Small skin tag
• Tenderness
• Sigmoidoscopy and proctoscopy under GA
TREATMENT:

CONSERVATIVE OPERATIVE
• Addition of fibre to the diet to bulk up - Lateral anal sphincteroromy
the stool
• Stool softener - Anal advance flap
• Adequate water intake
• Warm baths
• Topical application to relax internal
sphincter (nitric oxide donor-
scholefield) & analgesic agents. (GTN
0.2%, diltiazem 2%)
• Anal dilator- low compliance
Perianal abscess
Definition:
 A collection of pus and the formation of an abscess arising immediately
adjacent to the anal verge.
 If undrained, can expand into adjacent tissues- ischiorectal space,
supralevator space (Any abscess in anorectal region)
 Common in men between 20 to 50 years old.
Etiology
A perianal abscess originates from an infected anal crypt gland .

 Infection of an anal fissure

 sexually transmitted infections
 blocked perianal glands
 thrombosed external pile(perianal hematoma)
The abscess usually begins when bacteria ( bacteriodes ,
streptococus fecalis) enters through a tear in the lining of the rectum
or anus.
Conditions that predispose perianal abscess
•Crohn’s disease - fistula
•Diabetes mellitus
•Chemotherapy
•HIV infection
•Foreign body
•Trauma
Signs and Symptoms
Severe, trobbing pain  exarcebated by movement (sitting,
defecation)
 Tender swelling close to the anus
 General symptoms of abscess: malaise, LOA, fever
Cardinal signs of infection : fever , redness, swelling and loss of function typically
present.
 Perianal abscess:
 Pain and tenderness are greater due to confined space for expansion.
 Appear at perianal margin between the internal and external sphincters.
 Abscess discharge spontaneously
 Cherry sized seen and felt at the anal verge below the dentate line.
INVESTIGATION
● FBC – WBC level
● Sigmoidoscopy
● Trans rectal ultrasound
● rectal biopsy confirm diagnosis.
Management
Perianal abscess:
Drainage of the pus under general anaesthetic (drainage through
•
wrong space will create perianal fistula).
Pus sent for bacteriological assessment to determine causative
•
agent(s).
• Antibiotics are not needed in uncomplicated cases.
Parenteral antibiotics (eg. Broad-spectrum cephalosporins,
•
metronidazole) administered when there is extensive cellulitis, and
are mandatory for diabetic patient with perianal sepsis.
MANAGEMENT
• HEMORRHOIDS
• PERIANAL ABSCESS
 HEMORRHOIDS
• Conservative
• Medical
• Office Procedure
• Surgical

Treatment options vary by hemorrhoid severity or grade!

Conservative
Dietary and lifestyle modification:
• Eat more high fiber diet, fiber
supplements
• Drink plenty of water
• Exercise, go for a walk
• Don’t Strain and go as soon as you feel
the urge
• Try Epsom salt
• Topical treatment is warm (40oC) Sitz
bath
Medical
Emollient laxative
(also known as a stool softener)
Active ingredients: docusate
sodium and docusate calcium
How it works: It helps wet and
soften the stool.
Considerations for use: Stool
softeners are gentle enough to
prevent constipation with regular
use. However, they’re the least
effective option for treating
constipation. They’re best for people
with temporary constipation or mild,
chronic constipation.
Bulk-forming laxative
Active
ingredients: psyllium, methylcellulose,
and calcium polycarbophil
How it works: It forms a gel in your stool
that helps hold more water in your stool.
The stool becomes bigger, which stimulates
movement in your intestine to help pass
the stool more quickly.
Considerations for use: Bulk-forming
laxatives can be used for longer periods and
with little risk of side effects. They’re a
good option for people with chronic
constipation. However, they take longer
than other laxatives to work. You shouldn’t
use them continuously for longer than one
week without talking to your doctor.
Office procedure
1) Rubberband ligation
• Treat I-III degree hemorrhoids
• Cause strangulation of blood supply
• occlude base of hemorrhoid minimally 2cm above dentate line

2) Injection of sclerosants
• Treat I-III degree hemorrhoids
• Injection of a sclerosant into the apex of an internal hemorrhoid to provoke
fibrotic reaction
• Eg: phenol in oil, sodium morrhuate, quinine urea
• Successful rate of 75 – 90 %
• Recurrence is frequent, but retreatment is safe

3) Infra- red ligation

• Treat grade I and II hemorrhoids.
• Direct application of infrared waves that results in protein necrosis within
the hemorrhoid.
• Painless and uncomplicated
Surgical Procedures

INDICATION :
failed office procedures
large external hemorrhoids
Grade III or IV or combined hemorrhoids with significant prolapse

Types:
1. Hemorrhoidectomy (open/ closed)
2. Stapled Hemorrhoidopexy
3. Doppler-Guided Hemorrhoidectomy
HEMORRHOIDECTOMY
• Traditional hemorrhoidectomy remains very effective.
• Most effective treatment for grade III hemorrhoids
• Standard hemorrhoidectomy leaves open or closed wounds
• a/w increased pain and the highest complication rate
OPEN HEMORRHOIDETOMY (Milligan-Morgan)
 Ferguson’s (Closed) Haemorrhoidectomy
• Haemorrhoidal tissue excised.
• Mucosal wound and skin sutured completely with a continuous
absorbable suture.
HEMORRHOIDOPEXY
• A circular stapling device
that removal of abnormally
enlarged hemorrhoidal
tissue, followed by the
repositioning of the
remaining hemorrhoidal
tissue back to its normal
anatomic position
 PERIANAL ABSCESS
Surgical: incision and drainage
● Drainage of the pus under general anaesthetic, through
perineal skin, usually through a cruciate incision over the most
fluctuant point, with excision of skin edges to deroof of abscess.
● Pus sent for microbiological culture and tissue from wall for
histological to exclude specific causes.
● Antibiotics are prescribed if there is surrounding cellulitis and
patient that less resistant to infection (eg: DM)
ANAL FISTULA
(FISTULA IN ANO)
• Chronic abnormal communication which runs outwards from anorectal lumen (internal opening) to external opening on
skin of perineum / buttock / vagina
• Anal fistulae originate from the anal glands, which are located between the internal and external anal sphincter.
• If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface.
• Pathophysiology:
Etiology
• Strained evacuation of a hard
stool
• Repeated passage of diarrhoea
• Repeated trauma, anal
hypertonicity, vascular
insufficiency
Clinical Features
• Anal pain on defecation
• Bright red PR bleed (noticed
after wiping)
• Mucous discharge
• Constipation
• Ischaemic ulcer in midline of
anal canal
• May a/w Crohn’s disease, TB,
sexually transmitted / HIV-
related ulcers, squamous cell ca
 Park’s Classification
• Based on centrality of intersphincteric anal gland
sepsis

• 45% intersphincteric
• Do not cross ext sphincter
• Run directly from int to ext openings across distal int
sphincter
• May extend prox in intersphincteric plane
• 40% trans-sphinteric
• Primary track cross both int & ext sphincters
• Pass through ischiorectal fossa to reach skin of buttock
• Secondary track often reach roof of ischiorectal fossa
• May a/w circumferental spread of sepsis
• Supra-sphincteric
• Rare, iatrogenic
• Difficult to distinguish from high level trans-sphincteric
tracks (however, they share same management)
• Extra-sphincteric
• Run w/o specific relation to sphincter
• Often result from pelvic disease / trauma
Standard classification
• Low level: • High level:
• Open into anal canal below • Open into anal canal at or above
internal ring internal ring
• Lower but still risk to function • High risk of incontinence if laid
open
Investigations
CLINICAL:
Full examination under anaesthesia (EUA) following
Goodsall’s Rules:
• Indicate the likely position of int opening according
to position of ext opening
• Helpful but not infalliable
• EUA  fistula topography should be repeated
before surgical intervention
• Dilute hydrogen peroxide, instilled via site of ext
opening to look for site of int opening
• Gentle use of probes + a finger  delineate primary
& secondary tracks
 Endoanal
ultrasound

IMAGING:
• Proctosigmoidoscopy
• Sphincter strength
• Site of int & ext opening
• Course of primary track
• Presence of secondary extensions
• Presence of conditions complicating the fistula

• Endoanal U/S  sphincter integrity

• Manometry
• MRI: gold standard for fistula imaging
• Fistulography
• CT scan MRI of supra-
sphincteric fistula
Management
• Surgical
• Fistulotomy: in laid open of fistula (best
way of eradication)
• May leads to incontinence
• Fistulectomy: open excision of fistula
• Setons: sphincter preserving techniques
• Advancement flaps:
• Eliminate secondary tracks and acute sepsis
• Coring out entire track
• Closure of communication with anal lumen
• By adequately vascularized flaps consist of
mucosa & int sphincter
• Biological agents
• Conditions found in natal cleft overlying coccyx, consisting of one or more,
usually non-infected, midline openings, which communicate with a fibrous
track lined by granulation tissue and containing hair lying loosely within the
lumen
• Aka jeep disease
• Acquired theory of origin of piloidal sinus:
• Hair projecting from sinus + occupational accumulation of hair (hair dresser) at
interdigital cleft / axilla / umbilicus
• Buttock friction + shearing forces in the area allow collected hair to drill through
midline skin
• Create primary track (subcutaneous, chronic infected, midline track)
• Secondary track may spread laterally with discharging openings
• CF: intermittent pain, swelling, discharge at base of spine
• Hx of repeated abscess that burst spontaneously / incised
• Conservative mx:
• Cleaning tracks
• Removal of hairs
• Regular shaving
• Strict hygiene
• Tx of acute exacerbation (abscess):
• Rest, bath, local antiseptic drainage, broad spectrum antibiotics
• Drainage through small longitudinal incision over abscess + thorough curettage of granulation
tissue & hair
• Tx of chronic pilonidal disease
• Surgical: excision of all tracks with primary closure