( 25 pages )

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 ANO-RECTAL DISEASES

APPLIED ANATOMY:
HILTON’S LINE: it is the mucocutaneous junction or wavy white
line seen in the lower third of the anal canal on protoscopy.

Above this line is the rectum:

 Has autonomic sensation, sensitive only to stretch.
 Arterial supply from mesenteric vessels.
 Venous drainage to the portal circulation.
 Lymphatic drainage to the mesocolic glands.

Below the line is the skin of the anus:

 Has somatic sensation as sensitive as skin anywhere.
 Arterial supply from iliac vessels.
 Venous drainage to the iliac veins.
 Lymphatic drainage to the inguinal glands.

DIAGNOSIS OF ANAL CONDITIONS WHICH PRESENT WITH:

PAIN ALONE:
1- fissures
2- proctalgia fugax –pain spontaneously at night-
3- anorectal abcess
PAIN AND BLEEDING: fissures
PAIN AND A LUMP:
1-perianal hematoma
2- anorectal abcess
PAIN, LUMP AND BLEEDING:
1- prolapsed haemorrhoids
2- carcinoma of the anal canal
3- prolapsed rectal polyp or carcinoma
4- Prolapsed rectum

DIAGNOSIS OF CONDITIONS PRESENTING WITH RECTAL

BLEEDING BUT NO PAIN:
 Blood mixed with stool  colon carcinoma
 Blood streak on stool rectal carcinoma
 Blood after defaecation haemorrhoids
 Blood and mucus colitis
 Blood alone diverticular disease
 Melaena peptic ulcer

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 Bleeding and pain fissure or anal carcinoma

HEMORRHOIDS (PILES)
Heme = blood
Rhoids= flowing
Piles= ball
* it is the commonest cause of rectal bleeding
ANATOMY:
Within the anal canal there are anal cushions which contain
blood vessels (arterioles, venues, A-V fistula) muscles and
connective tissues.
These cushions are found at the ano-rectal junction above the
dentate line.
They lie in the left lateral, right anterior and right posterior
positions relative to the anal canal (3, 7, 11 o’clock position)
when the pt. lies in the lithotomy position.
In-between these 3 primary haemorrhoids (cushions) there
may be smaller secondary ones.

PATHOPHYSIOLOGY:
Anal cushions may become congested as a result of increased
intra-abdominal pressure (straining) or by compression of
superior rectal vein by a carcinoma in the rectum or by the
uterus of a pregnant women.

CAUSES:
1- carcinoma of the rectum: may compress or cause
thrombosis of the superior rectal vein piles

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 2- pregnancy: pregnant uterus compress superior rectal vein
also progesterone relaxes the smooth muscles of the veins
causing an increase in the pelvic circulating volume.
3- Chronic constipation: straining increases intra-abdominal
pressure. Hard stool passage traumatizes the cushion’s
wall.
4- Also, heart failure, excessive use of laxatives and portal
HTN are causes.
*internal and external haemorrhoids are differentiated by their
anatomical origin in the anal canal.

INTERNAL HAEMORRHOIDS:
-develops above the dentate line.
-covered by anal mucosa.
-lacks sensory innervation (painless)
-bright red or purple in color.

EXTERNAL HAEMORRHOIDS:
-arise below the dentate line.
-Covered by St. sq. epith.
-innervated by the inferior rectal nerve.

 Internal H. drains into sup. Rectal veins  portal system

 External H. drains into inf. Rectal veins I.V.C.

GRADING HAEMORRHOIDS :
Internal H. are classified by the degree of tissue prolapse into the
anal canal.

GRADE 1: they are confined to the anal canal with minimal

bleeding or maybe asymptomatic but do not prolapse.

GRADE 2: they prolapse on defecating or straining then reduce

spontaneously.

GRADE 3: prolapse with or without straining and require manual

reduction.

GRADE 4: chronically prolapsed and if reducible fall out again.

Others fall out of the anus and are irreducible (strangulated)
surgical emergency.

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PREDESPOSING FACTORS:
Most H. are idiopathic, but they may be precipitated by factors that
produce sup. Rectal vein congestion.
1- Compression by any pelvic tumour or pregnant uterus.
2- Cardiac failure or portal HTN.
3- Chronic constipation.
4- Use of purgatives (laxatives) excessively.
5- Rectal carcinoma.

SYMPTOMS:
Grade 1 usually are asymptomatic or with minimal bright red
bleeding on defecation.

1-bleeding:
-the main and earliest symptom
-starts as bright red bleeding on the surface of the stool or on the
toilet paper.
-it may continue intermittently for years or months.
-it often increases in frequency and severity until a steady drip of
blood accompanies defecation.

2-prolapse:
-a much later symptom
-starts transiently on defecation, but occurs with increasing
frequency until 3rd degree H. develop.

3-discharge:
-a mucous discharge accompanies a prolapsed pile.
-occurs when the columnar mucosa of the upper anal canal is
exposed.

4-pruritis: this will follow the discharge.

5-pain: they are painless unless if they are complicated by a

thrombus to a thrombosed pile.

SIGNS: the pt. should be in the left lateral position.

INSPECTION:
-1st degree H. show no outward abnormality

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-2nd degree H. may show the skin covered components when the
buttocks are separated or piles may prolapse when the pt. strains.
-3rd degree H. shows the red anal mucosa in their position (3,7,11)

DIGITAL EXAMINATION: internal H. can’t be felt unless they are

thrombosed or in the long standing thickened piles.
Browes book says don’t do PR.

PROTOSCOPY: it is the key investigation.

- When the protoscope is slowly withdrawn just below
the anorectal ring the H. will bulge into the lumen of
the protoscope.
- The pt. is asked to strain during the withdrawal so the
vascular engorgement is produced and the degree of
prolapse can be determined.
*don’t forget abdominal examination.

 Thrombosed piles: the skin around the anus is swollen and

edematous in relation to the pile bearing areas.

INVESTIGATIONS:
1-sigmoidscopy: essential to exclude co-exclude rectal
pathology as carcinoma or polyps.

2-barium enema: indicated when sigmoidscopy and

protoscopy can’t explain the symptoms.

3-CBC: anemia, rarely happen in longstanding piles.

DDx:
Anal or rectal cancer.
Redunculated polyps.
Rectal prolapse.
Anal fissures or fistula or hematoma – if painful-

COMPLICATIONS:

1- anemia: rarely may follow a sever or continuous bleeding

2- Strangulation: when a prolapsing pile become gripped by
the external anal sphincter.
3- Thrombosis: results from an occlusion of the venous return
by a strangulated pile. It is swollen, painful, tense and dark.

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 4- Ulceration: superficial ulceration of the exposed mucous
membrane.
5- Gangrene: when strangulation is so tight to constrict the
arterial supply of the H.
6- Suppuration: uncommon. Due to infection of the
thrombosed pile.
7- Fibrosis: after the thrombosis, the H. may be converted into
fibrous tissue.

TREATMENT:

1-first degree H.: bulk laxatives and high dietary fibers maybe
enough to decrease the constipation

2-injection therapy (sclerotherapy):

-for the 1st degree and early 2nd degree H.
-3-5 ml of 5% phenol in almond oil is injected through a special
syring to the base of the pile or just above the anorectal ring.
-It is a painless procedure if done properly because the high anal
canal area is painless.
-Bleeding should stop within 24-48 hours.
-Procedure may be repeated after a few weeks if necessary.

3- Rubber band ligation:

-effective with 1st and 2nd degree H.
-a small o-ring rubber band applied to constrict the mucosa at the
base. This will lead to strangulation of the pile and subsequent
sloughing of the pile over a period of 10 days or so.

4-infra-red photocoagulation.

5-cryotherapy: a cryoprope is applied to the overlying mucosa.

6-stretching of the anal sphincter: it improves venous drainage and

decrease the need for straining. Overstretching may lead to anal
incontinence.

7-haemorrhoidectomy:
Necessary for the 3rd degree H. or in prolapsed thrombosis.
Complications of the procedure:
Anal stenosis, acute urinary retention, post-operative hmg.

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 CARCINOMA OF THE RECTUM

 Carcinoma of the rectum accounts for approximately one

third of all tumours of the large intestine.
 Predisposing factors are pre-existing adenomas, familial
adenomatous polyposis and ulcerative colitis.
 Diagnosis is made on the basis of: the history, rectal
examination, sigmoidscopy and biopsy finally.
 75% occur in the lower part of the rectal ampulla
papilliferous or a simple ulcer with everted edges.
 25% in the upper part of the rectum annular in shape.
 90% or rectal cancers can be felt with a finger during PR.

MACROSCOPIC APPEARANCE:
It may be as follows:
 papilliferous
 ulcerating commonest
 stenosing at rectosigmoid
 colloid

MICROSCOPIC APPEARANCE:
*90% are adenocarcinoma
*9% are colloid – adenocarcinoma with mucous production-
*1% highly anaplastic carcinoma simplex
*at the anus, sq. cc occur but, a malignant tumour protruding
through the anal canal is more likely to be an adenocarcinoma
of the rectum invading the anal skin.

 Rectal ca is common in middle and old age (50-70 yrs)

but can occur in young adults.
 It is equally common in both sexes.

SYMPTOMS:
 Rectal bleeding: small dark red streak on the stool. If a lot of
blood accumulates it can pass as such but this is uncommon.
 The surface of the tumour produces mucous which is
expressed in a more liquid motion – diarrhea like- but if it pools it
can be passed as liquid faeces.
 There may be change in bowel habit usually towards
constipation.

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  High annular cancers at the rectosigmoid junction may cause
partial obstruction  presenting as alternating constipation and
diarrhoea.
 Tenesmus  tumour in the lower part of the rectum is large
to fool the sensory mechanisims into thinking it is faeces.
 Wight loss: this is common even if there isn’t any metastasis.
 Small primary lesions maybe symptom less but associated
with multiple metastasis especially to the liver. Here the pt. has
upper abdominal pain, malaise and a palpable mass.
 Pain is an uncommon symptom, but if present it could be:
1- Colic, with distension and vomiting. Caused by high annular
tumours obstructing the lumen.
2- Local pain in the rectum, perineum or lower abdomen. Caused
by direct spread of the tumour to the surrounding structures
especially the sacral nerves.
3- Pain on defecation, occurs if the tumour has spread
downwards below the mucocutanious junction into the
sensitive anal canal. It can mimic a fissure.

 Any pt. complaining of passing water through the

rectum, usually has rectal carcinoma or villous adenoma.
 In the past history, the pt. may have a long standing UC
which increases the risk of rectal ca after 10 or more years of
the disease.
 Also, the symptoms of cancer may be thought as a
recurrence of UC and could lead to late presentation.
 In the family Hx, polyposis – in which the entire colon
and rectum are carpeted by polyps one of which could turn
malignant at any time- may be present.

SIGNS ON EXAMINATION: on rectal examination:

 Usually nothing abnormal to see around the
anus, but you can see a low tumour protruding through the
anus.
 What can be felt depends upon the site of the
lesion.
 If the tumour is low in the ampulla, the finger can
feel the whole lesion.
 More commonly, only the lower edge of a
malignant ulcer can be felt. It feels hard and bulges into the
lumen of the rectum, the edges are everted and the base is
irregular and friable.

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 Upon withdrawal of the finger, you will have blood
and mucous on the gloved finger.
 If the tumour is in the upper part of the rectum,
only the lower edge is felt.
 This position of the lesion makes it hard to decide
if the tumour is in the rectum or out of it  sigmoidscopy is the
answer.
 PR is not reliable in fat people.
 On general examination: the liver is the most
common site for metastasis.
 Other sites for metastasis are: supraclavicular
lymph glands, the lungs and the skin.
 Lung metastasis is uncommon but because it is
small and peripheral not producing symptoms or signs, a chest
x-ray is mandatory.
 Lymph drains to the mesenteric LN then to the
pre-aortic LN which are rarely palpable. Meso-colic glands are
occasionally palpable on PR.
 The inguinal LN are involved only if the tumour is
below the Hiltons line to involve the skin.
 If the pt. has palpable inguinal LN, the tumour is
most likely to be sq. cc. of the anal skin.

SPREAD OF THE CANCER:

1-local:
a- circumferentially around the lumen of the bowel
b- Invasion through the muscles
c- Penetration into adjacent organs as prostate, bladder, vagina,
uterus, sacrum, sacral plexus, ureters and lateral pelvic wall.

2-lymphatic: to regional LN along the inferior mesenteric vessels.

At a late stage, there is invasion of the iliac LN and of the groin
LN –retrograde- and involvement of the supraclavicular nodes via
the thoracic duct.

3-blood: via the superior rectal venous plexus then the portal vein
to the liver and then to the lungs.

4-trans-coelmic: seeding of the peritoneal cavity.

STAGING OF RECTAL CARCINOMA: by Duke’s method:

A- Confined to the mucosa and the submucosa.

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B- Invasion of the muscle wall.
C- The regional LN are involved.
D- Distant metastasis has occurred eg: the liver, invasion of the
bladder.

PROGNOSIS:
Depends on the stage of progression of the tumour and on the
histological degree of differentiation. The more advanced the
spread and the more anaplastic its cells, the worse the prognosis.

SPECIAL INVESTIGATIONS:
1-sigmoidscopy: to inspect and take a biopsy.
2-barium enema: the indications for this procedure are:
* The growth isn’t visualized by sigmoidscopy
*if a second tumour is suspected
*ulcerative colitis
*familial polyposis
3-ultrasound of the abdomen to check liver metastasis and
ascites.

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 DDx OF RECTAL TUMOUR:
 Benign growth
 Carcinoma of the sigmoid prolapsing into the pouch of
Douglas.
 Secondary deposit in the pelvic
 Ovarian or uterine tumours
 Extension of a carcinoma in the prostate or cervix
 Diverticular disease
 Endometriosis
 Lymphogranuloma inguinale
 Amoebic granuloma
 Rare malignant tumours of the rectum
 Faeces – known by indentation on examination-

TREATMENT:

Curative:
 Surgery depends on the distance of the tumour from the
anal verge.
 Upper third tumours resection with anastomosis between
the sigmoid and lower rectum (anterior resection)
 Lower third tumours less than 5 cm from the anal verge
are ttt by abdominoperineal excision of the rectum +
terminal colostomy + adjunctive radiotherapy to reduce
recurrence.
 Mid third tumours anterior resection if distal clearance
can be obtained. This easier in women due to the wide
pelvic

Palliative procedure:
Even if secondary tumours are present, palliation is best
achieved when the primary is resected.
Colostomy is necessary for intestinal obstruction. But this
doesn’t relieve the bleeding, discharge and sacral pain.
In inoperable cases, deep x-ray therapy, diathermy, or laser of
the tumour may give temporary relief as may cytotoxic drugs.

DIVERTICULAR DISEASE

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  this disease may present in one of the following manners:
1-chronic left sided abdominal pain + change in bowel habits
2-acute abdominal symptoms
3- Rectal bleeding: acute, massive and fresh blood

 Elderly pt. with this disease present with a little faint, lower
abdominal pain, and a desire to defecate that when
emptied pass large volume of fresh blood and clots.
 The patients are rarely shocked and don’t require
transfusion.
 It is diagnosed via barium enema or colonscopy

 Causes of bleeding are:

1- eroded artery in the mouth of the diverticulum
2- the disease is incidental and the bleeding is due to
angiodysplasia of the chronic mucosa

 surgery is very rarely needed

PERI-ANAL HEMATOMA

 It is not a true hematoma but a thrombosis of a vein in the

subcutaneous plexus.
 There are no presepitating factors usually but causes could
be:
1-injury to the venous wall during anal stretching with defecation
2-after straining and stretching of the perineum during the
second stage of labour in child birth.

 An inflammatory reaction is present in the area with pain and

oedema.
 It can occur at all ages and in both sexes equally.
 It can occur any where in the anal area, be multiple or be
recurrent.

SYMPTOMS:
1- pain: usually due to the tension
*it begins gradually increasing in severity over a few hours and
subsiding gradually over few days
*it is continuous.

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*made worse by sitting, moving and defecating
*localized to the lump

2-swelling:
*appears at the same time as the lump
*First it is small and spherical
* Then it may enlarge and become more painful

3-bleeding: this happens only if:

*the lump bursts
*the skin over the lump ulcerates

4- The skin around the lump is itchy and moist due to the
leakage of the mucous because the lump doesn’t allow the
anus to close properly.

SIGNS ON EXAMINATION:
*Colour: if it is close to the overlying skin which is not
edematous, it is deep red-purple. But if the skin is edematous
then its colour can’t be seen.

*The lump is tender especially if it ulcerates.

*shape and size: initially the lump is spherical and up to 1cm in
diameter. If the skin is lax or edematous then the lump is
polypoid.

*surface: covered by skin and the surface beneath it is smooth

*composition: solid, hard hemispherical mass

*relations: the lump is superficial to the external sphincter. Not

fixed to the skin or other structures. Cannot be reduced to the
anal canal.

TREATMENT:
The symptoms may subside spontaneously after 2-3 days
during which analgesia is given. If it is in the acute phase and
the patient doesn’t want to wait, incision under local
anaesthesia is the way to go.

FISSURE-IN-ANO

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*anal fissure is a longitudinal split in the skin of the anal canal

PATHOPHYSIOLOGY:

An acute tear is common and usually heals quickly. Re-opening

of the tear when the pt. next defecates will cause more pain
causing an increase in the tone of the anal sphincter spasm
the tear is more likely to open at each defecation vicious
circle of tear-pain-spasm- and more tear then the base of the
lesion becomes fibrous no healing chronic ulcer.

*acute fissures are common in children who pass bulky stool

quickly
*chronic fissures are most common in the age group 20 and 40
years.
*chronic fissures are common in women after childbirth.
*anal fissures are more common in men than in women.
*multiple fissures may complicate Crohn’s disease.

SYMPTOMS:

1-Pain:
 fissures are the commonest cause of pain in the anal
verge
 both acute and chronic fissures are very painful
 it begins at defecation and is described as tearing

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  it persists for minutes to hours after defecation
 it is throbbing or aching in nature

2- Bleeding:
 acute fissures may streak the stool with blood and stain
the toilet paper
 Chronic fissures bleed less and may produce little blood
stain of the toilet paper if any.

3-a small skin tag called sentinel tag or sentinel pile may form at
the lower end of a chronic fissure. This tag may be felt by the pt.

4- Because of the pain, the pt. is usually constipated.

5-the fibrosis around the chronic fissure prevents a good seal

around the anus leading to small amounts of mucous leak on the
peri-anal skin pruritus –could be the presenting symptom of a
chronic fissure-

6-the symptoms are slow to develop and become long standing,

there may be periods of remission

 The majority of the fissures are in the midline posteriorly, but

some are anterior and a few are lateral.
 The diagnosis is made by inspection of the area after gently
parting the skin of the anus and seeing a split.
 The anal sphincter is in spasm and any attempt to open it or
doing PR is very painful this is contraindicated
 You can do PR only if the pain is not sever detecting the
defect in the anal canal skin. There will be a streak of fresh
blood on the gloved finger after withdrawal
 Never attempt to do sigmoidscopy or protoscopy without
anaesthesia. When done under an anaesthetic, the raw base
of the fissure will be seen as the instrument is withdrawn.

DDx: crohn’s disease, trauma (abuse of children), carcinoma, TB,

syphilis and psoriasis.

TREATMENT:

Acute fissures:
*if early and small may heal spontaneously.

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*local anaesthetic ointment + lubricant laxative relief
*application of GTN cream relaxes the anal sphincter healing of
the epithelium.
*more intractable cases respond to dividing the internal sphincter
submucosally under general anaesthetic.
*chemical sphincterotomy using an injection of botox into the
internal sphincter
*advantages of the chemical method are:
1-sphincter paralysis is short lived
2-gives a more sustained effect than GTN cream

Chronic fissures: require excision

FISTULA-IN-ANO

DEFENITION:
A fistula is a track lined with epith. Or granulation tissue,
connecting two epithelial surfaces. It may connect two body
cavities or one cavity and the body’s external surface.

A fistula-in-ano connects the lumen of the rectum or anal canal

with the external surface. It is ysually lined by granulation tissue.

CAUSES:
1-abscess:
In most cases, it is caused by an abscess in the inter-sphenteric
space bursting in two directions internally into the anal canal and
externally to the skin.

2-IBD: Crhon’s disease causes multiple painless fistulas. Here the

disease is primarily involving the terminal ileum.

3-low rectal carcinoma

CLASSIFICATION:
There are high level fistulas and low level fistulas. It is important to
differentiate between them as the surgical management of both is
completely different.
LOW LEVEL FISTULAS:
 The internal opening is below the anorectal ring

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  This ring is the point where the puborectalis muscle sling
fuses with the external sphincter
 The ring is the major muscle involved in maintaining
continence fistulas below it (low level) may be opened
without impairing continence.
 They could be of the following:
1-trans sphincteric
2-inter sphinteric
3-subcutaneous or submucous

HIGH LEVEL FISTULAS:

 The internal opening is above the anorectal ring.
 If opened, it may divide the ring and make the pt.
incontinent
 More complex surgery is required
 They could be of the following:
1-extra sphincteric (pelvirectal supralevator)
2-trans sphincteric
3-inter sphincteric

SYMPTOMS:
1- Watery or purulent discharge from the external opening of
the fistula. The pt. may notice bubbling on defecation as
mucous is forced through the fistula stop the fistula from
healing.

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 2- Pain is episodic as the fistula fills with pus. If the pus doesn’t
discharge pain is more intense and throbbing
3- The discharge causes pruritus ani.
4- There is no difficulty with defecation
5- There may be minor bleeding from the external opening
6- The symptoms in general are episodic but the condition
hardly ever cures itself

GOODSALL’S RULE:
The internal opening of an anterior fistula lies along a radial line
drawn from the external opening to the anus, whereas the internal
opening of a posterior fistula lies in the mid line posteriorly.

ON PR EXAMINATION:
 The external opening is visible anywhere around the anus
usually close to the anal margin but sometimes a few
centimetres away.
 The opening is not tender but the thickened tissue around it
may be.
 The serous or purulent discharge may be visible.
 Rectal examination is not painful.
 The internal opening may be felt. 2/3 are posterior, 1/3 are
anterior.

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  Sigmoidscopy and protoscopy are essential to exclude
underlying disease as chron’s or carcinoma or TB.
 The inguinal LN are not enlarged except if there is
inflammation or secondary infiltration by carcinoma.
 Don’t forget general examination if there is a suspected
systemic underlying cause.

INVESTIGATIONS: fistulogram, endoanal ultrasound, MRI

DDx: pilonidal sinus, hidradenitis, suppurative, incontinence,

chron’s, trauma.

TRAETMENT:
 Superficial and low level fistulas are laid open and allowed
to heal by granulation. There is no loss of continence
 This is only done if the fistula lies below the anorectal ring
 High fistulas (suprasphincteric, trans-sphincteric) only the
lower part of the fistula is laid open a non-absorbable
ligature (eg.: nylon) termed a seton is passed through the
upper part of the fistula left for 2-3 weeks the sphincter
is fixed by scar tissue subsequent division of the upper
part of the track either by a second operation or by
tightening of the ligature.
 Lying open the whole track will completely divide the
sphincter incontinence

ANORECTAL ABCESSES
CLASSIFICATIONS:
 Peri-anal:
 The swelling is at the anal margin which it distorts.
 It results from infection a hair follicle, a sebaceous gland or
a peri-anal haematoma.

 Pain and tenderness are greater here than in other classes,

as the space in which it expands is confined.
 The painful area could be anywhere around the anal margin.
 Submucous: infected fissure or laceration of the anal canal
 Pelvirectal: spread from pelvic abscess –rare-
 Ischiorectal:

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  From infection of the anal gland leading from the anal canal
into the submucosa, spread of infection from a peri-anal
abscess or penetration of the ischiorectal fossa by a foreign
body.
 The abscess may track as a horse shoe behind the rectum to
the opposite fossa.
 It lies lateral to the anus and occupies a much larger space.
 The patient with this class of abscess is much more likely to
be systematically unwell.

 It is not always possible to decide which sort of an abscess it is,

as the land marks cant be detected.
 Abscesses are commonest in patients between 20-50 yrs, but
occurs at any age even in children although rarely.
 It is more common in men.

PATHOPHYSIOLOGY:
Infection at anal gland pus either:
1-tracks down to the perineum between the sphincters perianal
abscess
2-penetrates the external sphincter to reach the ischiorectal fossa

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If the abscess is drained externally or bursts the anal gland is
destroyed.
If the abscess continues to secrete a fistula will develop.

SYMPTOMS AND SIGNS:

1-sever throbbing pain which makes sitting, moving, defecation
difficult and is exacerbated by them all.
2-a tender swelling close to the anus may be felt
3-the general symptoms of abscesses may be present- malaise,
loss of appetite, sweating, rigors.
4-the overlying skin is hot and red and tender
5- it is not possible to define the features of the mass

6- the size is assessed by palpation, the mass is to tender to elicit

fluctuation.
7-PR is possible but very painful anaesthesia
8- the abscess may bulge into the side of the lower part of the
rectum.
9-the inguinal LN are sometimes enlarged and tender.
10- on general exam tackycardia, pyrexia, sweating, dry furred
tongue and foetor oris.

TREATMENT: early surgical drainage to prevent rupture and fistula

formation – 30% of patients develop it-

STRICTURE OF THE ANAL CANAL

CLASSIFICATION:
1-conginital
2-traumatic: as postoperative after too radical excision of the skin
and mucosa in haemorrhoidectomy
3-inflammatory: lymphgranuloma inguinale –mostly female-, CD, UC
4-post-irradation
5-infiltrating neoplasm

TREATMENT: depends on the cause and may call for repeated

dilatation, plastic reconstruction, defunctioning colostomy, excision
of the rectum if malignancy is the cause.

PRURITIS ANI
CAUSES:

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1- local causes within the rectum or the anus. Any factor that causes
moisture of the area: poor hygiene, sweating, mucous from
haemorrhoids, proctitis, colitis, fistulas.
2- Skin disease: scabies, pediculosis, fungal infection: candida
3- General diseases associated with pruritis: DM, hodgkin’s
lymphoma, obstructive jaundice.
4- Idiopathic

TREATMENT: according to the cause. The idiopathic group

responds to hydrocortisone ointment and attention to hygiene.

PROLAPSE OF THE RECTUM

1-PARTIAL PROLAPSE:
 Confined to the mucosa that prolapses an inch or two from
the anal verge.
 Palpation of the prolapseno muscular wall in the prolapse.
 Happens in infants who are otherwise healthy.
 Treatment of these babies requires reassuring the parents as
the condition is self limiting
 If happens in adults, it is associated with prolapsed piles or
sphincter incontinence or pruritis ani.
 Treatment in adults is to excise the redundant mucosa, or a
submucosal phenol-in- oil injection in order to produce
sclerosis.

2-COMPLETE PROLAPSE:
 All layers of the rectal wall.
 Usually in elderly women that have naturally delivered
children.
 There is discomfort and incontinence due to the stretching
of the sphincter and the mucous discharge from the
prolapsed surface.
 Treatment:
1-Thiersch wire operation where a wire is passed around the
anal orifice to narrow it and reduce the prolapse. OR
2- fixation of the rectum in the pelvic by an abdominal
operation wrapping the rectum in sponge fibrous
reaction fixation.
3-Delorme’s procedure less traumatic perineal
approach excision of the mucosa and bunching of the bowel

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muscle to form a doughnut-like ring holds the rectum in the
pelvis rather as a ring pessary may control vaginal prolapse.

PILONIDAL SINUS

PILONIDAL= nest of hairs

It is a sinus that contains a tuft of hairs. However, it can occur
without hairs.

*it is found in the midline skin covering the sacrum and the
coccyx.
*they are sometimes also found between the fingers in
hairdressers, and in the umbilicus.
*it is lined by granulation tissue not by skin and there isn’t
hairs growing within it.
* The hairs are short, broken pieces that often come from the
scalp.

PATHOPHYSIOLOGY:
While walking, the motion of the buttocks on either side
results in hairs getting sucked into a pre-existing dimple in the
skin or actually piercing the normal skin. Then they act as
foreign bodies and cause chronic infection. The end result is a
chronic abscess which contains hair and flares up frequently
into an acute abscess.

*it is rare before puberty and in people over 30 years of age.

*it is a self limiting condition.
*it is more common in men, especially dark haired hirsute
men.

SYMPTOMS AND SIGNS:

 Pain and discharge are common when an abscess forms in
the tract.
 The pain varies from dull aching pain to acute throbbing
pain.
 The discharge varies from little serum to sudden gush of
pus.
 An acute abscess may be the first sign of the disease.
 In between the acute exacerbations, it produces few
symptoms and the patient may think it has disappeared.

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  The acute exacerbations happen at irregular intervals.
 If the sinus becomes chronic, it may discharge continually.
 It could be misdiagnosed as a fistula due to its proximity to
the anus.
 The sinuses are always at the midline of the natal cleft and
lie over the lowest part of the sacrum and coccyx.
 It is very rare for a sinus or an abscess to be closer to the
anus then to the tip of the coccyx.
 There could be more than one
 Sinuses could have edges that are: epitheliazed edges
puckered scarred edges, granulation tissue if the sinus is
discharging.
 The skin around the sinus is normal except if it is inflamed.
 If the sinus is infected, it is indistinguishable from other SC
abscess.
 A patient with pilonidal abscess finds some relief from the
throbbing pain by lying prone, in contrast to patients with
ano-rectal abscesses who prefer to lie on their side.
 The inguinal LN does not enlarge.
 The underlying sacrum, the skin of the perineum the anal
canal and the ischiorectal fossa should be normal.

NB: you can refer to BROWSE’S book last chapter in the 4 th

edition, lecture notes 11th edition chapter 26, churchill’s pocket
book of surgery pp 299-314.

‫وا ولي التوفيق‬,,,

‫ملكا الشمري‬

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