Download Chronic fissure

**Common Anorectal Conditions**
Dr. OSAMA ABU SALEM.
MD.JBGS.MRCSI
General In formations:
* Patients with a wide variety of anorectal lesions present
to physicians can be successfully managed in the office
setting.
* A high index of suspicion for cancer should be maintained
and all patients should be questioned about relevant family
history or other indications for cancer .
*Both surgical and nonsurgical treatments are available for
the pain of anal fissure.
*Infection in the anorectal area may present as different types
of abscesses, cryptitis, fistulae or perineal sepsis.
*Fistulae may result from localized infection or indicate
inflammatory bowel disease. *Protrusion of tissue through
the anus may be due to hemorrhoids, mucosal prolapse,
polyps or other lesions
**. A thorough
physical examination should be performed to detect
and evaluate all anorectal lesions.
This examination must include abdominal examination, visual
inspection of the anal and perineal areas, digital rectal palpation and
anoscopic visualization. Further testing and examination, including
sigmoidoscopy or colonoscopy, are indicated in select patients.
**** It is a grave error to automatically assume that every patient
who presents with common symptoms has only a benign condition
such as hemorrhoids.
*Cancer can coexist with benign lesions, so complete assessment is
necessary. Colorectal cancer
. can be cured only if found early.
Once cancer is ruled out, more than 90 percent of anorectal
complaints can be managed in the primary care physician's office
Fissure
A fissure is a small cut or split in the anoderm. It may be induced
by a hard bowel movement or straining at stool.
Fissures are most commonly located anterior or posterior to the
anus. When fissures are found laterally, syphilis, tuberculosis, occult
abscesses, leukemic infiltrates, carcinoma, herpes, acquired
immunodeficiency syndrome (AIDS) or inflammatory bowel disease
should be considered as causes
Sphincter tone is markedly increased, and digital examination
produces extreme pain.
Most fissures can be observed with gentle lateral
retraction around the anus.
*
* patients respond well to rectal suppositories containing
a topical corticosteroid and a local anesthetic.
*adequate relief of pain is essential . It is also extremely
important to keep the stool soft with a high-bulk diet to
avoid aggravating the fissure.
Acute posterior fissure .
Chronic fissure. Chronic fissures (external
perianal tag, or sentinal tag ,granulation
tissue)
Chronic fissure. Chronic
fissures (external perianal
tag, or sentinal tag
,granulation tissue)
.
Acute posterior fissure
*Chronic fissure :
usually require surgical treatment with lateral
sphincterectomy.
.
*** Sphincterotomy and nonsurgical treatments with
topical steroids and topical nitroglycerin, nifedipine and
diltiazem are available for anal fissure..
A nonsurgical treatment for anal fissure is nitroglycerin
ointment.and or other various preparations with additives such as a
local anesthetic, or phenytoin to aid the healing process.
Hemorrhoids
*Hemorrhoids are classified as internal, external
and mixed, based on their site of origin.
*External hemorrhoids begin below the dentate
line, while internal hemorrhoids originate above
the dentate line.
*Mixed hemorrhoids can indicate lesions that
originate at the dentate line, or the term can be
used to describe the presence of both internal
and external hemorrhoids
Thrombosed hemorrhoids are treated
by incision under local anesthetic to
remove the clot.
Conservative therapy with sitz baths
and pain medication may be indicated.
TREATMENT OF HEMORROIDS:
*External
Observation; local measures
Surgical excision
If thrombosed: observation, incision or excision
*Internal
Band ligation
Infrared coagulation
Radiofrequency treatment
Sclerotherapy
Surgical excision/laser
Anal tags
Surgical excision
Internal hemorrhoids are graded to IV:.
* Grade I- internal hemorrhoids bulge with defecation.
*Grade II hemorrhoids, prolapse occurs with defecation, but the
lesions recede spontaneously.
*Grade III hemorrhoids require digital replacement
*Grade IV cannot be replaced once they are prolapsed.
Thrombosed external hemorrhoids and perianal tags from "old"
disease
Prolapsed internal hemorrhoids, grade IV (long black arrow). The dentate line
(short black arrow) is indicated, and a small polyp (white arrow) is visible.
Fistula
The most common cause of anal fistula is
cryptoglandular infection. Infections that begin in the
anal glands can evolve and present as either abscesses
or fistulas. Fistulas are common in patients with
Crohn's disease.
Flexible sigmoidoscopic examination is indicated to
evaluate the mucosa of the distal colon for signs of
inflammatory bowel disease
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.
*
Abscesses
-Abscesses also begin as an infection in the anal glands
-The infection may track through the internal and external sphincter muscles to
enter the ischiorectal space
-Treatment options include surgical drainage into the rectum
Abscesses
Abscesses also begin as an infection in the anal glands
The infection may track through the internal and external sphincter muscles to enter the ischiorectal space
Treatment options include surgical drainage into the rectum
•Condyloma
Acuminatum
•
Extensive perianal
condyloma acuminata
This condition is
generally caused by
infection with human
papillomavirus 6 or 11.
The anal lesion of syphilis (condyloma
latum) is usually flat but, if raised, may
resemble condyloma acuminatum. Serologic
testing for syphilis helps distinguish lesions
Cryptitis
Cryptitis is a localized infection of one of the anal glands.
Perineal Sepsis
Pain in the perineal area, fever and inability to void form the classic triad
of signs of perineal sepsis. The most common cause is advanced
cryptoglandular infection resulting in a necrotizing perineal infection
Proctitis/Ulcerations/Inflammatory Bowel Disease
rectal discomfort, tenesmus, rectal discharge and constipation. The
rectal mucosa is often friable, and a mucopurulent discharge may be
present.
Mucosal Prolapse and Full-Thickness Rectal
Prolapse (Procidentia)
Mucosal prolapse is complete eversion of the anal mucosa.
On the other hand, rectal prolapse is a full-thickness
evagination of the rectal wall outside the anal opening. In
either situation, the treatment is usually surgical..
Anal Tags
Anal tags should be removed or a biopsy should
be obtained to confirm the etiology. Anoscopy
may enable the physician to identify the cause or
find other lesions
Hypertrophied Papillae
Stricture/Stenosis
can occur secondary to prior anal surgery or radiation therapy,
and can be a long-term complication of chronic anal fissure,
inflammatory bowel disease, perianal dermatopathy, anal cancer or
trauma.
The treatment is lysis of the fibrous cicatrix, with or without a
concomitant sphincterotomy. an advancement flap anoplasty. Hegar
dilators.
Polyps
Adenomatous polyps (tubular, tubulovillous and villous) are
precursors to cancer and are also termed "neoplastic polyps." They must
be distinguished from hyperplastic polyps, which are usually quite
small (less than 5 mm) and have no neoplastic potential, and the
nflammatory pseudopolyps associated with inflammatory bowel disease.
The finding of an adenomatous polyp, regardless of size, is an indication
for a total colonic examination. Biopsy is required to distinguish
hyperplastic polyps from small adenomatous polyps
Hypertrophied papilla.
Anal polyps require removal and, if they are confirmed to be adenomatous
(tubular, tubular-villous or villous), colonoscopy is required to rule out the
existence of proximal lesions
Chronic Solitary Ulcer
The cause of chronic solitary ulcer is unknown; the
lesion must be biopsied to make sure that it is not
neoplastic.
Cancer of the Anus and Rectum
Pain is usually absent, and rectal bleeding is inconsistent.
An external or internal mass may be palpable. Some
lesions are so soft that they are missed on palpation. Anal
cancer can take several forms, such as ulcers, polyps or
verrucous growths. Anal cancers are staged and treated
differently from rectal cancers. Most anal cancers respond
well to treatment with combined chemotherapy and pelvic
radiation
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 pathologic
study showed no cancer.
Anal cancer. This anal cancer had been treated for three 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.
Colorectal cancer is almost always treated surgically. Once these
cancers become symptomatic, the prognosis worsens, stage I, 95
percent of patients with colorectal cancer survive at least five years.
Once stage IV (distant metastases) the five-year survival is less than
10 percent, Anyone with a first-degree relative with colon cancer or
adenomatous polyps diagnosed before age 60 should have the entire
bowel screened for colon cancer at age 50, or 10 years before the age
of diagnosis in the relative.
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