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**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. ******************* THANK YOU ***************** **********************