常見肛周疾病

CommonOfficeAnorectalProblemsDisclosuresNoneBenignAnalRectalDisease

AnatomyoftheanalcanalandperianalspacesBenignAnalRectalDiseaseAbscessandFistulaFissureHemorrhoidsOverviewofAnatomyAnatomyPelvicandPerirectalSpacesAnatomyofAnalCanalRetrorectalSpaceWaldeyer’sFasciaSupralevatorSpaceLevatorAniMuscleDeepPostanalSpaceSuperficialPostanalSpacePeritoneumLevatorAnim.Puborectalism.

DeepExternalSphincterm.InternalSphincterm.TransverseSeptumSupralevatorSpaceIschioanalSpaceIntersphinctericSpacePerianalSpaceANALCANAL

ANALCANALAnalTransitionalZoneColumnofMorgagniDentateLineAnalCryptAnalGlandAnodermPatientcomplaintsAnalPainBleedingDrainageTimecourseFissureKnifelikepainwithBMPassingGlassBrick,ThrobingPainwithBM:minutestohoursBloodontoiletpaperNodrainageSmalltagor“hemorrhoid”HemorrhoidAcuteorChronicBleedingitchingburningSuddenswelling,+/-painProlapseDifficultywithhygienePainrarelyknifelikeAbscessGenerallyAcuteMinimalbleedingPainSwellingoverlargeareanotassociatedwithBM+/-PurulentDrainageRapidincreaseinsizeDiagnosisandTreatmentofAnorectalAbscessandFistula-in-AnoAnorectalAbscess

EtiologyCryptoglandularabscessMostcommonInfectionintheglandsatthedentatelineOthercausesCrohn’sandUlcerativeColitisTuberculosisandActinomycosesMalignancyForeignBodies,ProstateSurgeryorRadiationFistulaDescriptionClockdescriptionDoestheanustelltime?Reliesondescriptionofpatient’sposition:supine,lateral,proneandrelativelandmarksAnatomicdescription:moreconsistentPubicbonedefinesanteriorCoccyxdefineposteriorRightandleft*Iftermsbeincorrect,thenstatementsdonotaccordwithfacts;andwhenstatementsandfactsdonotaccord,thenbusinessisnotproperlyexecuted."Confucius1

TailboneRightanteriorRightposteriorLeftanteriorLeftposteriorRightLeftPubicboneThereisanareaofindurationanderythemaintherightposteriorquadrantthatislikelyanabscessthathasspontaneouslydrainedAbscessClassificationFourTypesBasedonSpaceInvolvedPerianal-19-54%Intersphincteric-20-40%Ischioanal-40-60%Supralevator2%orlessMostCommonRareSupralevatorAbscessPerianalAbscessIschioanalAbscessIntersphinctericAbscessSupralevatorSpaceIntersphinctericSpaceIschioanalSpaceHORSESHOEABSCESSAnorectalAbscess

TreatmentofPerianalandIschiorectalAbscessesDiagnosis-usuallystraightforwardErythemaandPainoveraffectedareaFluctuanceTreatmentIncisionandDrainage+/-ExcisionofsmallamountofoverlyingskinInitialpackingforhemostasisDrainagecatheter(Pezzer)orpackwoundAttentiontogoodhygieneandcontrolbloodsugarAntibioticsifimmunocompromised,obeseordiabeticSmallRadialincision

Shortdistancefromanus–feelforsoftspot

Placedrainandtrim–avoidspacking

Followupin7-10daystoremovedrainCatheterTypesPezzercatheterSolidmushroomtopsostaysinLesstissueingrowthMalecotAllowstissueingrowthMorepainfultoremovePerianalabscess-?AntibioticsNotusuallyindicatedifthereisadequatedrainageIndicatedforpatientswith:ObesityDiabetesImunocompromisedExtensivelargeabscessorrecurrentabscessFistula-in-Ano

Definitionabnormalconnectionbetweentwoepithelialsurfaces.Classification:Parks:DefinesfistulabycourseoftractGoodsall’sruleDiagnosisTreatmentGoalsOptionsHowdoespatientpresent?MayhavehadahistoryofabscessHistoryofCrohn’sdiseaseMaypresentatthesametimeasabscessComplainofintermittentincreaseinpain/swellingfollowedbyspontaneousdrainageChroniclocalizedareaofirritationorulcer“pimplenearmyanuskeepscomingback”Fistula-in-Ano

Goodsall’sRulePosteriorAnteriorFistulainanoFistulainano:SurgicaldiseaseRefertoColonandRectalSurgeonorGeneralSurgeonReassurepatient–rarelycancer,mostdonotneedacolostomyIfsuspectCrohnsGaincontrolofperianalsepsisThencompletefullworkupandstagingGoalsoftherapyGetridofthefistula/connectionPreservecontinenceSurgicalOptionsPrimaryfistulotomyMainlyforlow,superficialfistulaRiskoffecalincontinenceFibrinGlue/FistulaPlugUtilizessubstrateasscaffoldtofilltractDoesnotinvolvecuttingmuscleCuttingordrainingsetonsFordeepertractsthatinvolvesignificantmuscleRiskoffecalincontinenceRectaladvancementflapLateralinternalfistulatransectionNewerprocedure.NoforeignsubstrateCutsfistulatract,notmuscleFistulainanoFistulainanoFissureinAnoDefinition–apainfullinearulcersituatedintheanalcanalandextendingfromjustbelowthedentatelinetothemarginoftheanusOverliethelowerhalfoftheinternalsphincter~73.5%areposterior~16.4%areanterior~2.6%bothanteriorandposteriorFissureinAno

PathogenesisAcutefissureresultsfromtraumatotheanalcanalmostcommonlyfromalargefecalbolusSecondarychangesofchronicfissureincludeSentinelpileorskintagatthedistalendHypertrophiedanalpapilla-swelling,edemaandfibrosisnearthedentatelineFibrosisoftheinternalsphincteratthebaseFissurewithSentinelTagFissurewithSentinelTagFissureinAno

PathogenesisPerpetuatingfactorsinchronicfissurePersistenthardbowelmovementAbnormalhighrestingpressureintheinternalanalsphincterIncreasedpressureinthesphinctercausesadecreaseinbloodflow,preventinghealingofthefissureFissureinAno

SymptomsPainisthemainsymptomSharp,cuttingortearingduringdefecationDurationisfewminutestohoursBleeding–brightredandscantSkinTagMucousdischargeresultinginitchingFissureinAno

DiagnosisDiagnosisoftenmadeonhistoryaloneInspection–gentlyspreadthebuttocksandthefissurebecomesapparentTriadofchronicanalfissureSentinelpileHypertrophiedanalpapillaAnalulcerFissureinAno

DifferentialDiagnosisIntersphinctericabscessPruritusAniFissurefrominflammatoryboweldiseaseCarcinomaoftheanusInfectiousPerianalconditionsLeukemicinfiltrationFissureinAno

Crohn’sAnalFissuresAcuteFissureinAno

TreatmentIncreasedietaryfiberLocalanesthetictopreventspasmNitroglycerinorNifedepineOintmentNotcommerciallyavailableMustbemixedbypharmacistWarmtubsoaks4-6weeksoftreatmentChronicFissureinAno

SurgicalTreatmentIndicatedonChronicnon-healinganalfissureandfissurethatisrefractorytomedicaltherapyLateralInternalSphincterotomyForcesthemuscletorelaxV-YAnoplastyflapAllowcoverageoffissurewithhealthytissueHemorrhoidsWhatarethey?Wherearethey?Whydotheybecomesymptomatic?Classification?Howdoyoutreatthem?Cantheybeavoided?Hemorrhoids

Whatarethey?Specializedhighlyvascularcushionsconsistingofdiscretemassesofthicksubmucosathatcontainbloodvessels,smoothmuscleandconnectivetissueAidinanalcontinenceHemorrhoids

Wherearethey?InternalHemorrhoids3majorbundles–leftlateral,rightanteriorandrightposteriorAbovethedentatelineBlooddrainsintothesuperiorrectalvesselsthenintotheportalcirculationExternalHemorrhoidsBelowthedentatelineBlooddrainsthroughtheinferiorrectalveinstothepudendalveinsonintotheiliacveinsHemorrhoids

Symptoms?ChronicconstipationDiarrheaTraumatothehemorrhoidsduringdefecationcausethemostcommonsymptomsPain–generallynot“knife-like”ItchingBurningBleedingHemorrhoids

Classification-InternalHemorrhoids1stdegree–bulgeintothelumen2nddegree–prolapsewithbowelmovementbutreducespontaneously3rddegree–prolapsespontaneouslyandrequiremanualreduction4thdegree–permanentlyprolapsedhemorrhoidsthatcannotbereduced4thDegreeHemorrhoidsHemorrhoids

TreatmentPrinciplesThoroughphysicalexamtodetermineseverityandruleoutotherpathologyReferforsurgicalevaluationifwhiteordiscolored,firmorfixedDetermineiftheproblemisinternal,externalorbothAssessthesymptomcomplexTreatmentTopicalagents:Proctofoam,AnusolHCAnalpram,Proctosolcream…ConservativetherapyBulkagents–i.e.highfiberFruits,vegetables,oatbran,psylliumIncreasewaterintakeAvoidcaffeinatedbeveragesAvoidprolongedsittingonthecommodeWarmtubsoaksTreatment

OfficeandMinorProceduresRubberbandligationPerformedintheofficeIndicatedforGrade1and2internalhemorrhoidsBandisappliedthroughananoscopeatthetopofaninternalhemorrhoidSevereperianalsepsis–ClassicTriadDelayedanalpainUrinaryretentionFeverTreatment

OfficeandMinorProceduresInfraredPhotocoagulationIndicatedin1stdegreehemorrhoidsCausesphotocoagulationofsmallvesselsPerformedinofficeor“HemorrhoidReliefCenter”MinimalpainClosedHemorrhoidectomy

IndicationHemorrhoidsareseverelyprolapsedandrequiremanualreplacementPatientsfailtoimproveaftermultipleapplicationsofnon-operativetreatmentHemorrhoidsarecomplicatedbyassociatedpathologysuchasulceration,fissure,fistula,largehypertrophiedanalpapillaorextensiveskintagsClosedHemorrhoidectomy

GeneralPrincipleMostcanbeperformedwithlocalandIVSedationProne/KraskepositionisthebestInfusetheareawithlocalanestheticwithepinephrineforhemostasisFleetsenema1-2hourspriorNoantibioticprophylaxisisnecessaryClosedHemorrhoidectomyClosedHemorrhoidectomyClosedHemorrhoidectomy

PostopResultPPHStaplingProcedureforHemorrhoidsNotforeveryhemorrhoidIdealforGrade2and3withminimalexternalcomponentPreventsprolapseandthuslesstraumatohemorrhoidwithbowelmovementPPHStaplingProcedureforHemorrhoidsPPHStaplingProcedureforHemorrhoidsBenefitsLesspainascomparedtotraditionalclosedhemorrhoidectomyLessbloodlossduringtheprocedureLesschanceofanalstenosisPPHStaplingProcedu