Hemorrhoids And Anal Problems

ANORECTAL PROBLEMS By

Dr.Ahmed Noureldin Ahmed (MBBS,DCH,DTM&H (Cairo PHC , Umm-Ghoilina

Rectal Anatomy

Anorectal Diseases

:We will discuss to day 10 topics Hemorrhoids- 1 Rectal Prolapse-2 Solitary Rectal ulcer Syndrome-3 Anal Fissure-4 Perianal Abscess-5 Anal Fistula-6 Anorectal Infection-7 Pruritus Ani-8 Fecal Incontinence-9 Squamous Cell Carcinoma of anus-10

-Hemorrhoids 1 are abnormally enlarged and dilated veins around .anus ?What are the causes It can be hereditary with congenital weakness of the vein walls. In men, due to erect posture there is high pressure in rectal veins. Straining by constipation and over purgation. Dysentery may aggravate latent hemorrhoids. Haemorrhoids are also common among pregnant women. The pressure of the foetus in the abdomen, as well as hormonal changes, .cause the haemorrhoidal vessels to enlarge

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Hemorrhoids A- Internal hemorrhoids Are a plexus of superior hemorrhoidal veins located above the dentate line, which are covered by mucosa , they are a .normal anatomy that occur in adults They are occur in three primary location, RT anterior, Rt posterior and Lt lateral . Smaller hemorrhoids may occur between these primary locations

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Views of internal hemorrhoid dentate line and ext,hemorrhoides

B- External hemorrhoids arise from the inferior hemorrhoidal► vein located below the dentate line .and covered with squamous epithel .of the anal canal or perianal region Hemorrhoids become symptomatic ► as a result of activities that increase :venous pressure such as

Activities That increase the Venous Pressure Straining at school ■ Constipation■ Prolonged sitting ■Low fiber diets ■ ,Pregnancy ■Obesity■ Which result in distention and enlargement of .Superior and/or inferior hemor.veins plexus With time → redundancy and enlargement of these veins may develop and result in bleeding . or Protrusion

Thrombosed external hemorrhoids (long arrow) )and perianal tags from "old"disease (short arrow

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Prolapsed internal hemorrhoids, grade IV (long black arrow). The dentate line (short black arrow) is indicated, and . a small polyp (white arrow) is visible

Symptoms and signs

Symptoms and signs Internal hemorrhoids patient complain of bleeding and mucoid discharge. Bleeding is bright red blood range from streaks of blood,visible on toilet paper to bright red blood that drips after .bowel movement

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This 's what hemorrhoids feels like

Stages of Internal Piles :There are 4 stages of Internal Piles Stage 1 : Piles confined to the anal canal ■ Stage 2 : piles prolapse during straining and■ .reduces spontaneously

Stage 3 : when prolapsed require manual reduction■ Stage 4: become chronically prolapsed■ Discomfort & pain are unusual in internal piles, which occur only when there is extensive inflammation and thrombosis of irreducible internal hemorrhoids. Or with thrombosis of external pilse

On Examination :Non-prolapsed Internal hemorrhoids► Are not visible, but may protrude with straining while the

.physician spreads the buttocks :Prolapsed Internal hemorrhoids► Are visible as protuberant purple nodules covered by mucosa

:External hemorrhoids► Are readily visible on perianal inspection in the form of perianal nodules covered with skin that may reach several centimeters .in size

The peri-anal region► should be examined for other signs of disease such as fistulas , fissures,skin tags,or dermatitis

Position for Rectal Digital (Examination (PR

Treatment Conservative ttt in stage 1 and 2 Decrease straining with defecation ■ High Fiber Diets ■ Increase fluid intake with meals ■ Mucoid discharge prevented by cotton ball■ tucked to anal opining

:For edematous , prolapsed pilse■ gentle manual reduction• .supp.that contain anesthetic and astringent• warm sitz baths•

Surgery Injection of Sclerotherapy► Rubber Band Ligation► Surgical Excision►

Thrombosed External Piles Thrombosis of external hemorrhoidal plexus results in a peri anal hematoma. It commonly occur in healthy young adults Which is precipitated by coughing,heavy lifting .Or straining at stools It is characterized by : acute onset of painful,tense, and bluish perianal nodule covered with skin. Pain is severe within the first few hours and gradually decrease over .2-3days

External hemorrhoid after seven .days of thrombosis

Treatment Warm Sitz Baths ■ Analgesics ■ Ointment ■ In the first 48 hrs. removal of the clot .under local anesthesia

?How is a Hemorrhoid treated Warm soaks ( sitz baths) several times a day can significantly reduce the pain, especially after a painful bowel movement. Topical anesthetics can also be used to reduce the pain of a thrombosed hemorrhoid. Antiinflammatory topical treatments (such as proctoFoam® HC (hydrocortisone acetate 1% and pramoxine hydrochloride 1%) and proctoCream® HC 2.5% (hydrocortisone acetate 2.5%) can soothe the irritation and pain. Hydrocortisone is a commonly used anti-inflammatory agent and is found in a number of medications. Astringent compresses can also be used for soothing purposes Bulk fiber laxatives, such as Citrucel are often recommended to reduce strain on the rectal area. Fiber may create softer larger stools, reducing straining and helping sensitive tissue heal faster, naturally

How can a Hemorrhoid be prevented

Prevention of hemorrhoids involves: normal bowel movements. Avoiding the straining associated with constipation is very important. Stool softeners and food or supplements that add bulk to stool are often used. Bulk forming agents include bran and other whole grains, fiber . supplements, fruits and vegetables Proper hydration to keep stool soft is important therefore increasing water intake beneficial

Rectal Prolapse- 2 It is protrusion through the anus of some or all the layer of the , rectum . It arises from chronic excessive straining at stool in conjunction with weakening of pelvic support structures Initially prolapse reduces spontaneously after defecation, with time the rectal mucosa becomes .chronically prolapsed

Symptoms Mucous Discharge ■ Rectal Bleeding ■ Fecal Incontinence ■ Sphincteric Damage ■

Anal mucosal prolapse (Lt ) and . ) full-thickness rectal prolapse (Rt

Solitary Rectal Ulcer Syndrome :Characterized by Anal Pain♣ .Excessive straining at stools♣ .Passage of mucus and blood♣ .It is most commonly seen in young women Proctoscopy reveals → either shallow ulceration (single or multiple) or nodular mass located anteriorly cm above anal verge 6-10 .Biopsy is diagnostic Treatment ; decrease straining at stools► use bulking agents ►

:Bulking Agents

Dietary Fibers- 1 Wheat Bran- 2 Methyl Cellulose- 3 Mucilaginous gums – sterculia-4 Mucilaginous seeds and seed- 5 coats, e.g. ispaghula husk (Fybogel Sachets(

Chronic solitary ulcer (arrow). The only way to confirm that this lesion is not a cancer is to obtain a biopsy. This .lesion was removed, and further tests showed no cancer

Anal cancer (arrow). This had been treated for 3 months with steroid suppositories although the patient had never had a physical examination. Simple inspection of the external anal area allowed the .physician to identify this aggressive tumor

Anal fissures Anal fissures are linear or rocket .shaped ulcers , usually < 5 mm in length It occurs commonly in the post. midline , but .10% occur anteriorly it is caused by trauma to the anal canal■ during defecate hard stool patients c/o of severe, tearing pain during ■ .defecation followed by throbbing discomfort Constipation due to fear of pain ■

On Examination By inspection of the anal verge while gently► separating the buttocks acute fissures look .like cracks in the epithelium Chronic fissures result in fibrosis and the► development of skin tag at the outer-most )edge ( sentinel piles .PR may cause severe pain►

Acute posterior fissure (arrow). Anterior and posterior fissures are most common. If fissures are located laterally, other etiologies must be considered. Fissures can often be identified by merely spreading the glutei but generally require anoscopy

Chronic fissures may present as an external perianal tag, or sentinal tag .)(black arrow The proximal end may also have granulation tissue that appears as an anal polyp (white arrow). When the condition is this advanced, a lateral .sphincterotomy is usually required

Treatment Fiber Supplements■ Warm Sitz Bath■ Topical Agents: 1% hydrocortisone oint■ Nitroglycerin Oint. Bid for 6-8 Wks % 02-0.5■ Recently, injection of Botulinum Toxins( 20 Units) into■ internal anal sphincter, induce healing in 90% of .Chronic Anal Fissure Surgery → Lateral Partial Internal Sphincterectomy■

Perianal Abscess is infection of anal glands located at► the base of the anal crypts at the . dentate line :Other causes► .anal fissure , and crohn’s disease

Symptoms Continuous , throbbing Perianal Pain ♣ Erythema , fluctuant mass , is found in ♣ thew peri anal region or in the ischio-rectal .Fossa on P/R examination :Treatment Local incision and drainage Ischio – rectal abscess require drainage in► the operating room

Sites of Perianal Abscesses

Peri anal Fistula Most often arises in an anal crypt■ Usually preceeded by an anal abscess■ In patients with fistula that connect to rectum ,other■ disorders such as : Crohn’s dis,lymphogranuloma venerium, rectal TB and carncer should be considered Fistulae are associated with purulent discharge ,that■ may lead to itching,tenderness and pain Treatment By incision or excision under anaesthesia

Common sites of anal fistulae Note subcutaneous fistulae do not traverse the sphincters, whereas low and high fistulae do

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.External site of perianal fistula

.External site of perianal fistula This patient presented with "just a little blood when I wipe." When anoscopy revealed no anal pathology closer inspection allowed the physician to identify . this papular area The wooden end of a cotton-tipped applicator was inserted 3 cm confirming a fistula, and the patient was referred for surgery. In addition to simple fistulotomy, treatments include cutting or draining setons, endo-anal mucosal advancement flaps, sliding cutaneous advancement flaps, fistulectomy with muscle . repair and fibrin glue injection

Blood on the end of a cotton-tipped applicator being withdrawn from a fistula .that could easily have been missed

Anorectal Infections Proctitis Is an inflammation of the distal 15 cm of .the rectum It is characterized by anorectal discomfort , tenesmus , constipation and discharge :Most cases are sexually transmitted e.g N.Gonorrhea ☻ Treponema Pallidum☻ Chlamydia trachomatis ☻H.S. type 2☻ Venereal Warts☻

Procto-colitis Is an inflammation that extends above the ■ .rectum to sigmoid colon or more proximally :It is caused by different organisms such as■ Campylobacter ☻E. histolytica☻ Shigella ☻E.Coli☻ It is manifested by : Frequent small volume ► ,bloody diarrhea , urgency and tenesmus

Pruritus Ani It is characterized by perianal itching and discomfort :Causes Over anal hygene associated with fistula fissures- 1 , prolapsed hemorrhoids,skin tags, and minor .incontinence Over cleaning with soaps may lead to irritation- 2 or contact dermatitis Pinworm 4-Candidiasis-3 Scabies 6-Condylomata acuminata- 5 Idiopathic- 7

Perianal dermatitis caused by .chronic pruritus ani

Treatment

Treat the cause- 1 Good cleaning with tap water only- 2 followed by gentle drying after bowel movement A piece of cotton ball tucked to anal- 3 opening to absorb perspiration or fecal seepage Anal ointment and Lotion should be- 4 avoided as it may exacerbate the .condition

.)Anal tag (arrow

Fecal Incontinence Fecal incontinence is present in up to 10% of the elderly There are 5 principles for bowel :continence Solid or semi solid Stools- 1 A distensible rectal reservoir- 2 A sensation of rectal fullness- 3 Intact pelvic nerves and muscles-4 The ability to reach a toilet in - 5 proper time

Minor Incontinence many patients c/o of slight soilage of :undergarment, which occur in After bowel movement■ With straining or coughing■ With local anal problems which make anal■ sphincter not work properly such as hemor. , skin tags in ch.diarrhea,IBS & ulcerat.proctits ■ Elderly may require more time or■ assistance to reach a toilet Elderly patient with chronic constipation■ may develop stool impaction leading to overflow incontinence

Major Incontinence Complete uncontrolled loss of stool means problem with shincteric .damage or neurological damage :Causes of sphincteric damage include► Traumatic Childbirth ■ Episeotomy■ Anal Surgery ■Physical Trauma■ :Causes of neurological damage includes► Obstetric trauma ■ Aging■ Dementia ■ Multiple Sclerosis■ Spinal Cord Injury ■ Cauda Equina Syndrome■ DM■

Treatment Bulking Agents- 1 (Anti-diarrheals ( Lopramide 2mg- 2 Anal Sphincter exercise-3 Treat the cause if possible- 4 Surgery in Major incontinence , if- 5 medical treatment fails

SQUAMOUS ( EPIDERMOID ( CELL CARCINAMA OF THE ANUS these tu. are relatively rare■ Incidence comprising only 1-2% of all■ .cancers of the anus and large gut In>80% of cases , human papilloma■ virus (HPV)may be detected :The commonest symptoms are► Bleeding , Pain , local growth of tumor The lesion is often confused with■ hemorrhoids or other anal disorders

These tumors tend to become annular ,■ invade the sphincter , and spread upward via the lymphatics into the perirectal mesenteric lymph nodes Occur regularly in AIDS patients■ Treatment depend on the tumor■ stage The 5 year survival rate is 65% for■ localized tumor,and over 25% for .metastatic disease

Common Anorectal Condition External hemorrhoids- 1 Anal Fissure- 2 Pruritus Ani- 3 Internal hemorrhoids- 4 Dentate line- 5 .Rectum- 6

Differential Diagnosis of Rectal bleeding

Causes of lower gastrointestinal bleeding The sites shown are illustrative - many of the lesions can be seen in. other parts of the colon

Rectal polyp It is like a tumor in the rectum that comes out at times leading to fresh bright red blood after stools, which are normal in consistency and non-painful

DDx of Rectal Bleeding Colorectal carcinoma-1 Polyps-2 Ischaemic colitis-3 Diverticular disease-4 Ulcerative colitis or Crohns colitis-5 Infectious proctitis-6 Hemorrhoids-7 Anal fissure-8 Solitary ulcer of the rectum-9 Rectal prolapse-10

REMEMBER THAT Hook worm is the most common cause of chronic-1 GI blood loss Massive bleeding from lower GIT is rare , and-2 .usually due to Diverticular dis. or Isch. colitis .Small bleeds from Piles occur very common-3 Procto-sigmoidoscopy should be done in all-4 patients with hematochezia(bleeding per rectum ) to exclude disease in the rectum or sigmoid colon that could be mis-interpreted in the presence of hemorrhoidal bleeding Patients with iron deficiency anemia should- 5 undergo colonoscopy or barium enema to exclude .disease proximal to the sigmoid colon

‫أشكر لكم حسن أستماعكم‬ ‫والسلم عليكم ورحمة ال وبركاته‬ ‫‪.‬‬