Transcript Back to medical school

Back to medical school
-anorectal disorders
Ian Botterill, Dept Colorectal Surgery
Leeds General Infirmary
Wide variety of pathologies
• congenital / acquired
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benign / malignant
traumatic
infective / inflammatory
gender / age related
Common symptoms of ano-rectal
disorders
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bleeding
anal pain
itch
faecal leakage / hygiene problems
swelling
discharge
Examination
• abdomen
• groins (lymph nodes)
• dermatoses
Ano-rectal examination
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chaperoned
relaxed patient
left lateral
good light
knee elbow position
use pt’s hand to elevate
right buttock
• +/- anoscopy in 1y care
Ano-rectal examination
• External appearance
-skin condition
-swellings
-soiling / discharge
-perineal descent
-scars
• Digital examination
-sphincter tone
-squeeze pressure
-cervix / prostate
-coccyx
-retrorectal space
-rectocoele
Anatomy
Haemorrhoids
• Symptoms:
- anal canal bleeding, pruritus, swelling, pain
Haemorrhoids
• Classification
- 1y: bleed, do not prolapse
- 2y: prolapse & reduce spontaeously
- 3y: prolapse & require manual reduction
- 4y: prolase, not reducible
Cause of haemorrhoidal problems
• altered bowel habit
• raised intra-abdominal pressure
• straining
Treatment of haemorrhoids
• Diet
-five helpings fibre / d
• Out-patient
-injection sclerotherapy
-banding
-photocoagulation
Surgical treatment
• For 3rd / 4th degree haemorrhoids
• Open haemorrhoidectomy
• Closed haemorrhoidectomy
• Ligasure haemorrhoidectomy
• Stapled haemorrhoidopexy (PPH)
Results of haemorrhoidectomy
• >90% daycase
• least initial pain
-stapled haemorrhoidopexy
-Ligasure haemorrhoiodectomy
• quickest return to work:
-stapled haemorrhoidopexy
-Ligasure haemorrhoidectomy
• most costly: PPH / ligasure
• lowest recurrence (prolapse) ; conventional
Complications of
haemorrhoidectomy
• Local
- stenosis
- faecal leakage
- recurence
- bleeding
- retention of urine
• severe perineal sepsis (esp IDDM &
immunosuppressed)
Painful prolapsed haemorrhoids
• natural history (worst pain days ~ 3-7, then settles)
• most resolve with conservative Rx
- lactulose / topical anaesthetic creams / ice / paracetamol & NSAIDs /
relief of anal spasm (GTN or diltiazem)
- failure to resolve > haemorrhoidectomy
- refer gangrenous or those that fail to settle
• interval haemorrhoidectomy if still problematic
Anal skin tags
Sx:
anal swelling / hygiene problems
Diagnosis:
perineal examination alone
Differential:
Crohn’s disease / anal warts
Rx:
reassurance / excision
Rectal mucosal prolapse & full
thickness rectal prolapse
Rectal mucosal prolapse
• result of straining
• associated with pruritus ani / mucous
discharge
• diagnosis @ anoscopy
• Rx
- dietary correction
- advised to avoid straining at stool
- injection sclerotherapy
Ano-rectal sepsis
Sx:
perineal pain (throbbing), possible prior history of similar
Exam:
tender fluctuant mass +/- discharge, may be toxic
Beware: diabetics (risk of rapidly progressive infection & Fournier’s gangrene)
skin necrosis (possible Fournier’s gangrene)
anal spasm & throbbing pain (inter-sphincteric abscess)
Treatment: I&D
Fistula in ano
~ 30-40% of all perineal sepsis once drained goes on to develop
a fistula
~ 80-90% of perineal sepsis that yielded enteric organisms will
develop a fistula
Fistula in ano
• 95% cryptoglandular
- ie origin in ano-rectal crypts at dentate line
• 5% rarities
- Crohn’s
- TB
- hidradenitis suppurativa
- traumatic
- malignancy
- complicated diverticular disease
- radiation
- anastomotic leakage
Classification
Inter-sphincteric
70%
Trans-sphincteric
25%
Supra-sphincteric
~5%
Extra-sphincteric
<1%
Simple v. complex
‘Complex’:
-branching tracts / 2y tracts
-associated abscess
-associated pathology
Goodsall’s rule
External opening posterior to 3-9
oclock position open in posterior
midline of the anal canal
External opening anterior to 3-9 oclock
position open radially in the anal canal
~80-90% accurate
Management of fistula in ano
Strike a balance between
-cure of fistula
-prevention of further anorectal abscess
-preservation of continence
Management of fistula in ano
• Divide tissues overlying track ( to allow healing by 2y
intent)
- lay open
- cutting seton
• Occlude internal opening & provide external drainage
- anal fistula plug
- rectal or anal advancement flap
• Prevention of further ano-rectal sepsis
- draining seton
Anal fissure
• ‘focal linear deficiency of anal mucosa’
• posterior > anterior
• acute v. chronic
-chronic: IAS exposed , > 6/52, keratinisation
• simple v. complex
Anal fissure
Anal fissure management
• stool softeners
• dietary advice
• topical LA
• chemical sphincterotomy
-topical
-injected
• surgical sphincterotomy
Anal fissure surgery through the
ages
• anal stretch
• lateral sphincterotomy
• chemical sphincterotomy
- topical
- injectable
Anal fissure treatment
• GTN
• Diltiazem
• Botox
• Sphincterotomy
40-50% successful
s/e: severe headaches
60-80% successful
s/e: nil generally
60-90% successful
s/e transient minor leakage
98% successful
s/e 2% passive leakage
Proctitis
• Biopsy mandatory (with exception of prior
prosate / cervical brachytherapy)
• UC / Crohn’s / indeterminate / infective
• Stool culture
• Biopsy prior to starting suppositories
• Suppositories often preferable to oral therapy
Pilonidal sinus / & abscess
Abscess often deep-seated – do not respond to antibiotics
Pilonidal sinus disease
Z plasty
Uli Szymanovski
Developed ‘Z’ plasty wound closure
Rhomboid flap
Healing by 1y intention ~90% of time as with Z plasty
Healing by 2y intent
Healing using Vac Therapy
Perianal haematoma
• Thromobosis of superficial haemorrhoidal
veins
• Discrete circular lump at / beyond anal
verge
• Incise & drain
Pruritus ani
Night > day
Rule out coexistent dermatoses / renal failure / liver disease
If fungal disease suspected > skin scrapings
Ano-rectal examination & proctoscopy.
Treat ano-rectal pathology (haemorrhoids / faecal incontinence / anal
tags etc).
Pruritus treatment
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Avoid synthetic / tight underwear
Avoid perfumed soaps etc
Avoid scratching
Use hairdryer to dry skin
Avoid steroid creams
Treat anal pathology / diarrhoea
Dermatology involvement
• Methylene blue injections > ~80% successful
- s/e occasional cellulitis / ulcer /
incontinence
Faecal incontinence
- understand continence first!
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Brain / higher centres
Spinal cord
Reflex arcs
Pudendal nerves
Ano-rectal sensation ‘sampling’
Stool consistency
Rectal compliance
Anal sphincter complex
Faecal incontinence
• Causation
• Obstetric injury (8-30% sphincter injury rate at childbirth)
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Post-surgical
Faecal impaction
Neuropathy / MS / Parkinson’s
Poor mobility / impaired cognition
Diarrhoea
IBS / rectal non-compliance
Assessment of faecal incontinence
• History
• Examination
• Endoanal USS (sphincter injury)
• Anorectal manometry (rest & squeeze strength)
• Pudendal nerve terminal latency (sensation)
Assessment of incontinence
• Cleveland clinic score
- severity of soiling
- frequency of soiling
- use of pads
- lifestyle disruption
• History of back injury / neurolgical disorder
• Urinary incontinence
• Saddle anaesthesia
Treatment incontinence
• dietary measures
• treat diarrhoea / impaction / IBS
• non-operative
- collagen injections
- anal plug
• sacral nerve stimulation
• sphincter repair
• artificial sphincters
• graciloplasty
Anal stenosis
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Post-surgical
Cancer
Crohn’s
Previous chronic anal fissure
• Radiation
• Systemic sclerosis
• Need EUA to assess all these
Anal cancer
Sx:
itch, bleeding, pain (if below dentate line), swelling,
ulcer, groin node
Exam:
hard, irregular, friable area. Groin nodes possible. ?
Coexists with anal warts
Differential:
haemorrhoids, anal fissure, anal warts, STD
Diagnosis:
EUA & biopsy
Anal cancer
-treatment
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Chemo-radiotherapy
Ongoing perineal surveillance
Average local control ~ 70%
Average cure ~ 70%
Salvage surgery for recurrence
- APER with rectus flap to perineum
• Rarely is local excision alone sufficient
Hidradenitis suppurativa
Superficial fistulating condition ass’d with chronic skin sepsis
Axillae > groins > perineum
Clinical diagnosis (+/- biopsy) – typically have disease elsewhere
Rx: drain sepsis / rotating antibiotics / infliximab / stop smokng
Anal papillae
Sx:
nil (asymptomatic finding typically)
Diagnosis:
at anoscopy
Biopsy:
rarely required
Treatment:
leave alone
AIDS & the perineum
• Wide variety of pathology
- fissures / abscesses / fistulae / infections / anal
cancer / cutaneous lymphoma
- florid warts
- pruritus
- incontience
• General principle
- suspect immunocompromise
- culture / biopsy
- avoid agresssive surgery
- treat in conjunction with Infectious Diseases
/ Sexual Health
AIDS
HSV
Other perineal problems
-pressure sores
Post-sacral
Over ischial tuberosity
Normally have clear cut antecedant history
summary
• diverse pathology
• high degree of overlap between 1y and 2y
care
• refer bleeding
• refer ‘odd-looking’ lesions