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1. Congenital. i) Strictures at the level of anal valves, due to incomplete obliteration of proctodeal memebrane ii) Spasmodic: Anal fissure causing spasm of the internal sphincter, with time becomes fibrotic
3. Organic: i) Postoperative stricture incorrectly performed haemorrhoidectomy ii) Irradiation stricture: strictures following radiations iii) Senile anal stenosis: seen in elderly, in which there is chronic internal sphincter contraction
iv) Lymphogranuloma inguinale: most common cause of tubular inflammatory stricture. 80% are women. v) Inflammatory bowl disease: stricture of anorectum occurs following ulcerative proctocolitis and large bowl Crohns disease. Stricture is annular vi) Endometriosis: recto vaginal septum may present as stricture.
Clinical Features a) Difficulty in defecation b) Pipe-stem shaped stool. c) In inflammatory srtricture, tenemus, bleeding and passage of muco-pus. d) Acute or chronic intestinal obstruction sometimes may occur
Rectal Examination Sharply defined shelf like interruption of the the lumen. Biopsy of the stricture is necessary.
TREATMENT
1.Prophylactic passage of anal dilator during convalescence of hemorroidectomy greatly reduces the incidence of postoperative stricture. 2. Dilatation by bougies for anal and many rectal strictures dilatation by bougies at regular interval is sufficient
Incision and primary Free skin Graft: for post- operative and senile strictures, this procedure gives better results 4) Colostomy : when stricture is causing intestinal obstruction 5) Rectal excision and colo-anal anastomosis when stricture is at or just above the ano-rectal junction and associated with normal anal canal
Incidence
1.5%-2% of all digestive system malignancies in the US increasing incidence over the last 30 years from 10 to 20 million cases(5000 in year) Carefully conducted epidemiologic studies showed that cure of anal CA can be possible in majority of patients with preservation of the anal sphincter
Female gender Multiple sex partners(Having many sexual partners) Cigarette smoking a Receptive anal intercourse HIV Age( Being over 50 years old.) IBD
hemorrhoids, fissures, fistulae case reports of anal CA in patients with IBD led to conclusion that it was result of sexual activity Increased risks with 10 or more lifetime partners
Epidemiology
Anatomy
Lymphatic drainage
above dentate line drains to the perirectal & perivertebral nodes
Histology
74% Epidermoid Carcinoma Squamous Basaloid Mucoepidermoid 19% Adenocarcinoma 4% Melanoma 3% Neuroendocrine/carcinoid/
sarcoma(leiomyosarcoma/lymphoma sarcoma)
Location
Anal canal tumors Pathologic classification of tumors in this area is difficult no easily identifiable landmarks between rectum and anus & transition zone has widely variable histologic appearance some have abrupt transition from glandular rectal tissue to anal squamous tissue others have intervening segment of junctional mucosa (basaloid or cloacogenic mucosa)
Clinical presentation
45% rectal bleeding 30% pain/sensation of rectal mass 20% no symptoms Mass in anus
Itching
A change in bowel habits.
Diagnosis
History P.E(T.R..) Anoscopy..Rectoscopy Endoscopy C.T MRI
Biopsy:
Follow up : Preop chemoradiation therapy and subsequent APR if there is Residual tumor in postradiation biopsy Combined chemoradiation therapy results in local failure 14-37%, 5 year survival rates 72-89%, and 5 year colostomy free survival rates of 70-86% after confirmation through multiple
Anal canal tumour APR (with permanent colostomy) 5 year survival rate 40-70% with 3% perioperative mortality rate
Epidermoid Carcinoma
Epidermoid carcinoma of the anus includes squamous cell carcinoma, cloacogenic carcinoma,
Epidermoid Carcinoma
transitional carcinoma, and basaloid carcinoma. Wide local excision is usually adequate treatment for these lesions.
Epidermoid carcinoma occurring in the anal canal or invading the sphincter cannot be excised locally First-line therapy relies upon chemotherapy and radiation. (the Nigro protocol: 5-fluorouracil, mitomycin C, and 3000 cGy external beam radiation). More than 80% of these tumors can be cured by using this
Recurrence usually requires radical resection (abdominoperineal resection). Metastasis to inguinal lymph nodes is a poor prognostic sign.
Radical resection and/or radiation therapy may be required for large lesions.
Paget's disease.
Wide local excision is usually adequate treatment for perianal Paget's disease.
Melanoma
prognosis for patients with anorectal disease remains poor Local resection with free margins does not increase the risk of local or regional recurrence and APR offers no survival advantage over local excision