Acute perianal conditions

Anatomy
2

Anatomy of the anal canal

The anal canal is
divided into two
unequal sections,
upper and lower:
1) The upper 2/3 : Its
mucosa is lined
bysimple columnar
epithelium.
2) The lower 1/3 of the
anal canal is lined
bystratified squamous
epithelium.
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Blood Supply
The upper 2/3 of the anal canal:
- is supplied by thesuperior rectal
arterywhich is a branch of theinferior
mesenteric artery.
- Is drained by superior rectal vein inferior
mesenteric vein
The lower third of the anal canal:
- is supplied by theinferior rectal arterywhich
is a branch of theinternal pudendal artery.
- Inferior rectal vein internal pudendal vein
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Physiolog
y
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Physiology
The function of the anal canal is to maintain continence.
This function is made by the presence of:
1)Internal sphincter: smooth muscle; involuntary.
2)External sphincter: skeletal muscle; voluntary.
3)Levator ani muscle: voluntary.
4)Dilated cushions: Hemorrhoids; finest closure.
Resting tone of anal canal is made by:
internal sphincter + some external sphincter and levator
ani.

Hemorrhoi
ds
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Hemorrhoids
Pathophysiology:
Engorgement and dilatation of the blood vessels
leading to stretching of the overlying mucosa and
formation of lumps that may prolapse.

Hemorrhoids
Classification:
1) Internal Vs External hemorrhoids.
2) Primary Vs Secondary hemorrhoids.

Hemorrhoids
Internal Vs External hemorrhoids:
- Internal hemorrhiods: above dentate line
(internal plexus)
- External hemorrhiods: below dentate line
(External plexus)
- Mixed hemorrhiods: above and below
dentate line.

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Hemorrhoids
Internal Vs External hemorrhoids:
-Internal hemorrhoids = columnar

epithelium (pink)
-External hemorrhoids = Squamous
(opaque)

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Hemorrhoids
Primary Vs Secondary hemorrhoids:

-Primary hemorrhoids: one or more

of the main vessels of anal canal are
involved (3,7,11 oclock in lithotomy
position)

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Hemorrhoids
Secondary hemorrhoids: smaller branches are
involved
Circumferential hemorrhoids: all around the
anal canal severe condition.

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Hemorrhoids
Degrees of hemorrhoids:
1st degree: no prolapse outside (only bleeding)
2nd degree: prolapse, spontaneous reduction
after defecation
3rd degree: prolapse, manual reduction
4th degree: permanent prolapse (irreducible)

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Hemorrhoids
Clinical Presentation:
Uncomplicated hemorrhoids: heaviness type of
pain after long standing or after defecation.
complicated hemorrhoids : Acute sharp pain

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Hemorrhoids
Complications:
Thrombosed hemorrhoids.
- Clinical presentaions : Severe sharp pain
in the first 48 hours.
- Physical examination: Tender tense blue
subcutaneous swelling at anal margin covered
by smooth shinny skin.
- Management: Most cases resolve
spontaneously within 2 weeks with
conservative therapy.
Some cases may require excision for pain
relief.
Strangulation (strangulated hemorrhoids
may become gangrenous and slough off)
Ulceration

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Hemorrhoids
Management
It depends on the severity of the case and the response
of the patient.
Conservative:
High fiber diet + Bulk laxatives
Interventional (non-surgical):
1. Sclerosing agent injection.
2. Cryosurgery.
3. Rubber band ligation.
.Surgical hemorroidectomy
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Anorectal
abscess
18

Anorectal abscess
It is a collection of pus in the anal/rectal region.
- Common in pts between 20-50 years old, but occurs at
all ages, rarely, in children.
- More often in men.

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Anorectal abscess
Pathophysiology
The most acceptable theory is the cryptoglandular theory:
1. Inflammation in the crypts (cryptitis).
2. Infection spreads through the ducts to the
anal gland (glandulitis).
3. Formation of (intersphincteric abscess)
This is the starting point of anorectal sepsis.
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Anorectal abscess
Clinical presentation:
Throbbing pain; which is aggravated by sitting
or movement.
Systemic symptoms: Fever, malaise, toxicity...

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Anorectal abscess
>> If the abscess remains there, then the patient will present with
intersphincteric abscess.
>> If the pus goes down, the collection will be at the anal
verge and the
patient will present with a bulge in the perianal skin (perianal
abscess).
>> If the pus goes up above the levator-ani muscle (supra
levator
abscess)
>> If the pus can pass through the external sphincter to
the ischiorectal
Space (ischiorectal abscess)
So the problem starts in the intersphincteric space but it can end
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anywhere.

Anorectal abscess
Physical examination: depends on the site
1. In perianal abscess the perianal skin is red,
tender and swollen.
2. In supralevator abscess deep pain with little or
no outside physical findings.
3. In intersphincteric abscess, if you do PR
examination you'll find a tender mass.
4. In ischiorectal abscess it depends on the site:
- in high level little or no external findings
- in low level red tender and swollen skin
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Anorectal abscess

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Anorectal abscess
Management:
Incision and drainage
Once you decide to drain the abscess, you have to
warn your patient that there is a chance around 50%
of recurrence and 50% of fistula formation.

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Pilonidal
abscess
and sinus

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Pilonidal abscess/sinus
The term pilonidal sinus describes a condition found in
the natal cleft overlying the 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.

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Pilonidal abscess/sinus
It is thought that the combination of buttock friction and shearing
forces in that area allows shed hair or broken hairs which have
collected there to drill through the midline skin

OR that infection in relation to a hair

follicle allows hair to enter the skin by
the suction created by movement of the
buttocks, so creating a subcutaneous,
chronically infected, midline track.
It may occur in: the umbilicus, the axilla, the interdigital area in
hairdressers.
Risk factors:
- Males - Hairy
- long sitting time

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Pilonidal abscess/sinus
Clinical presentation:
- Intermittent pain especially if inflamed or with
superimposed infection.
- Swelling and discharge

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Pilonidal abscess/sinus
Management:
Conservative
Clean the tract, remove hair
Regular Shaving
Strict hygiene

Surgical Excision

Acute pilonidal abscess: Usually requires incision and

drainage under local anesthesia
Chronic pilonidal sinus: Excision under general
anaesthesia with exploration, open and removal of tracts

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Anal
Fissure
31

Anal Fissure
It is a tear in the lower part of the anal canal
mucosa.
Cause:

Constipati
on

Intern
al
sphinc
ter
spasm

Pain

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Anal Fissure

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Anal Fissure
Clinical presentation:
Severe Pain: associated with defecation, usually
resolves spontaneously after a variable time to
recur again after the next evacuation.
Bleeding with defecation.
Constipation.
Mucus discharge pruritis.

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Anal Fissure
Classification:
Primary Vs Secondary
Acute Vs Chronic

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Anal Fissure
Primary Vs Secondary:
Primary fissures:
- Unknown cause (cycle)
- Location:
Midline posteriorly 90%
Midline anteriorly 10%
Secondary fissures:
- ( IBD , HIV , Syphilis , TB , Herpes, Leukemia)
- Not at the midline

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Anal Fissure
Acute Vs Chronic:
Signs of chronicity:
- Deep with a lot of

fibrosis.
- Proximal end of the
fissure: Reactionary
polyp (hypertrophied
anal papilla)
- Distal end of the
fissure: Sentinel piles or
skin tags

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Anal Fissure
Management:

Cons
tipati
on

Pain

Intern
al
sphin
cter
spas
m

The aim is to break the cycle

A) Conservative:
- Treat constipation; high fiber diet and bulk
laxatives
- Relieve pain: Local analgesics, sitz baths
- Relieve spasm: Nitroglycerin, Botulinum toxin, CCB
(relax the spasm, improve blood supply to improve
healing).
B) Surgery:
- Partial lateral internal sphinctertomy: reduces 38
tightness of the internal sphincter by cutting part of it.

Herpes
infection
(vesicles)

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Herpes infection
Sexually transmitted disease.(STD)
Very painful.
In early stage we can treat it
with antiviral drugs, but in late
stage we have to wait for the disease
to limit by itself.

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Rectal
prolapse
41

Rectal prolapse
It is the protrusion of wall of rectum through the
anus.

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Rectal prolapse
Clinical presentation:
- Mainly protrusion of a reddish mass from the anal
opening, especially following a bowel movement.
- Pain, bleeding, incontinence.
Management:
- Conservative : high fiber diet , bulk laxatives
- Surgery : abdominal rectopexy

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Proctalgia
fugax
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 Attacks of severe pain, arise in the rectum, recur at

irregular intervals, unrelated to organic diseases
[functional GI disorder]
Etiology:
No clear etiology
Probably caused by a spontaneous spasm of the
pelvic muscles
Clinical Presentation: Rectal pain
Comes suddenly at night
Severe, cramp like
Short duration [few minutes]
Disappears spontaneously
May follow stool straining, sudden explosive

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 Management:
-The most common approach is simply reassurance
and topical treatment.
-Warm baths, hot enemas
(if the pain lasts long enough to draw a bath).
-Relaxation techniques, medications.
-In patients who suffer frequent, severe, prolonged
attacks, inhaledsalbutamolhas been shown in some
studies to reduce their duration.
-Botulinum toxinhas been proposed as analgesic.
- Low dosediazepamat bedtime has been suggested
as preventative.

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The End
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