常見肛周疾病

常見肛周疾病第1頁/共67頁DisclosuresNone第2頁/共67頁BenignAnalRectalDisease

AnatomyoftheanalcanalandperianalspacesBenignAnalRectalDiseaseAbscessandFistulaFissureHemorrhoids第3頁/共67頁OverviewofAnatomyAnatomyPelvicandPerirectalSpacesAnatomyofAnalCanal第4頁/共67頁RetrorectalSpaceWaldeyer’sFasciaSupralevatorSpaceLevatorAniMuscleDeepPostanalSpaceSuperficialPostanalSpace第5頁/共67頁P(yáng)eritoneumLevatorAnim.Puborectalism.

DeepExternalSphincterm.InternalSphincterm.TransverseSeptumSupralevatorSpaceIschioanalSpaceIntersphinctericSpacePerianalSpaceANALCANAL

第6頁/共67頁ANALCANALAnalTransitionalZoneColumnofMorgagniDentateLineAnalCryptAnalGlandAnoderm第7頁/共67頁第8頁/共67頁DiagnosisandTreatmentofAnorectalAbscessandFistula-in-Ano第9頁/共67頁AnorectalAbscess

EtiologyCryptoglandularabscessMostcommonInfectionintheglandsatthedentatelineOthercausesCrohn’sandUlcerativeColitisTuberculosisandActinomycosesMalignancyForeignBodies,ProstateSurgeryorRadiation第10頁/共67頁FistulaDescriptionClockdescriptionDoestheanustelltime?Reliesondescriptionofpatient’sposition:supine,lateral,proneandrelativelandmarksAnatomicdescription:moreconsistentPubicbonedefinesanteriorCoccyxdefineposteriorRightandleft*Iftermsbeincorrect,thenstatementsdonotaccordwithfacts;andwhenstatementsandfactsdonotaccord,thenbusinessisnotproperlyexecuted."Confucius1

第11頁/共67頁TailboneRightanteriorRightposteriorLeftanteriorLeftposteriorRightLeftPubicbone第12頁/共67頁Thereisanareaofindurationanderythemaintherightposteriorquadrantthatislikelyanabscessthathasspontaneouslydrained第13頁/共67頁AbscessClassificationFourTypesBasedonSpaceInvolvedPerianal-19-54%Intersphincteric-20-40%Ischioanal-40-60%Supralevator2%orlessMostCommonRare第14頁/共67頁SupralevatorAbscessPerianalAbscessIschioanalAbscessIntersphinctericAbscess第15頁/共67頁SupralevatorSpaceIntersphinctericSpaceIschioanalSpaceHORSESHOEABSCESS第16頁/共67頁AnorectalAbscess

TreatmentofPerianalandIschiorectalAbscessesDiagnosis-usuallystraightforwardErythemaandPainoveraffectedareaFluctuanceTreatmentIncisionandDrainage+/-ExcisionofsmallamountofoverlyingskinInitialpackingforhemostasisDrainagecatheter(Pezzer)orpackwoundAttentiontogoodhygieneandcontrolbloodsugarAntibioticsifimmunocompromised,obeseordiabetic第17頁/共67頁SmallRadialincision

Shortdistancefromanus–feelforsoftspot

Placedrainandtrim–avoidspacking

Followupin7-10daystoremovedrain第18頁/共67頁CatheterTypesPezzercatheterSolidmushroomtopsostaysinLesstissueingrowthMalecotAllowstissueingrowthMorepainfultoremove第19頁/共67頁P(yáng)erianalabscess-?AntibioticsNotusuallyindicatedifthereisadequatedrainageIndicatedforpatientswith:ObesityDiabetesImunocompromisedExtensivelargeabscessorrecurrentabscess第20頁/共67頁Fistula-in-Ano

Definitionabnormalconnectionbetweentwoepithelialsurfaces.Classification:Parks:DefinesfistulabycourseoftractGoodsall’sruleDiagnosisTreatmentGoalsOptions第21頁/共67頁Howdoespatientpresent?MayhavehadahistoryofabscessHistoryofCrohn’sdiseaseMaypresentatthesametimeasabscessComplainofintermittentincreaseinpain/swellingfollowedbyspontaneousdrainageChroniclocalizedareaofirritationorulcer“pimplenearmyanuskeepscomingback”第22頁/共67頁Fistula-in-Ano

Goodsall’sRulePosteriorAnterior第23頁/共67頁Fistulainano第24頁/共67頁Fistulainano:SurgicaldiseaseRefertoColonandRectalSurgeonorGeneralSurgeonReassurepatient–rarelycancer,mostdonotneedacolostomyIfsuspectCrohnsGaincontrolofperianalsepsisThencompletefullworkupandstagingGoalsoftherapyGetridofthefistula/connectionPreservecontinence第25頁/共67頁SurgicalOptionsPrimaryfistulotomyMainlyforlow,superficialfistulaRiskoffecalincontinenceFibrinGlue/FistulaPlugUtilizessubstrateasscaffoldtofilltractDoesnotinvolvecuttingmuscleCuttingordrainingsetonsFordeepertractsthatinvolvesignificantmuscleRiskoffecalincontinenceRectaladvancementflapLateralinternalfistulatransectionNewerprocedure.NoforeignsubstrateCutsfistulatract,notmuscle第26頁/共67頁Fistulainano第27頁/共67頁Fistulainano第28頁/共67頁FissureinAnoDefinition–apainfullinearulcersituatedintheanalcanalandextendingfromjustbelowthedentatelinetothemarginoftheanusOverliethelowerhalfoftheinternalsphincter~73.5%areposterior~16.4%areanterior~2.6%bothanteriorandposterior第29頁/共67頁FissureinAno

PathogenesisAcutefissureresultsfromtraumatotheanalcanalmostcommonlyfromalargefecalbolusSecondarychangesofchronicfissureincludeSentinelpileorskintagatthedistalendHypertrophiedanalpapilla-swelling,edemaandfibrosisnearthedentatelineFibrosisoftheinternalsphincteratthebase第30頁/共67頁FissurewithSentinelTag第31頁/共67頁FissurewithSentinelTag第32頁/共67頁FissureinAno

PathogenesisPerpetuatingfactorsinchronicfissurePersistenthardbowelmovementAbnormalhighrestingpressureintheinternalanalsphincterIncreasedpressureinthesphinctercausesadecreaseinbloodflow,preventinghealingofthefissure第33頁/共67頁FissureinAno

SymptomsPainisthemainsymptomSharp,cuttingortearingduringdefecationDurationisfewminutestohoursBleeding–brightredandscantSkinTagMucousdischargeresultinginitching第34頁/共67頁FissureinAno

DiagnosisDiagnosisoftenmadeonhistoryaloneInspection–gentlyspreadthebuttocksandthefissurebecomesapparentTriadofchronicanalfissureSentinelpileHypertrophiedanalpapillaAnalulcer第35頁/共67頁FissureinAno

DifferentialDiagnosisIntersphinctericabscessPruritusAniFissurefrominflammatoryboweldiseaseCarcinomaoftheanusInfectiousPerianalconditionsLeukemicinfiltration第36頁/共67頁FissureinAno

Crohn’sAnalFissures第37頁/共67頁AcuteFissureinAno

TreatmentIncreasedietaryfiberLocalanesthetictopreventspasmNitroglycerinorNifedepineOintmentNotcommerciallyavailableMustbemixedbypharmacistWarmtubsoaks4-6weeksoftreatment第38頁/共67頁ChronicFissureinAno

SurgicalTreatmentIndicatedonChronicnon-healinganalfissureandfissurethatisrefractorytomedicaltherapyLateralInternalSphincterotomyForcesthemuscletorelaxV-YAnoplastyflapAllowcoverageoffissurewithhealthytissue第39頁/共67頁HemorrhoidsWhatarethey?Wherearethey?Whydotheybecomesymptomatic?Classification?Howdoyoutreatthem?Cantheybeavoided?第40頁/共67頁Hemorrhoids

Whatarethey?Specializedhighlyvascularcushionsconsistingofdiscretemassesofthicksubmucosathatcontainbloodvessels,smoothmuscleandconnectivetissueAidinanalcontinence第41頁/共67頁Hemorrhoids

Wherearethey?InternalHemorrhoids3majorbundles–leftlateral,rightanteriorandrightposteriorAbovethedentatelineBlooddrainsintothesuperiorrectalvesselsthenintotheportalcirculationExternalHemorrhoidsBelowthedentatelineBlooddrainsthroughtheinferiorrectalveinstothepudendalveinsonintotheiliacveins第42頁/共67頁Hemorrhoids

Symptoms?ChronicconstipationDiarrheaTraumatothehemorrhoidsduringdefecationcausethemostcommonsymptomsPain–generallynot“knife-like”ItchingBurningBleeding第43頁/共67頁Hemorrhoids

Classification-InternalHemorrhoids1stdegree–bulgeintothelumen2nddegree–prolapsewithbowelmovementbutreducespontaneously3rddegree–prolapsespontaneouslyandrequiremanualreduction4thdegree–permanentlyprolapsedhemorrhoidsthatcannotbereduced第44頁/共67頁4thDegreeHemorrhoids第45頁/共67頁Hemorrhoids

TreatmentPrinciplesThoroughphysicalexamtodetermineseverityandruleoutotherpathologyReferforsurgicalevaluationifwhiteordiscolored,firmorfixedDetermineiftheproblemisinternal,externalorbothAssessthesymptomcomplex第46頁/共67頁TreatmentTopicalagents:Proctofoam,AnusolHCAnalpram,Proctosolcream…ConservativetherapyBulkagents–i.e.highfiberFruits,vegetables,oatbran,psylliumIncreasewaterintakeAvoidcaffeinatedbeveragesAvoidprolongedsittingonthecommodeWarmtubsoaks第47頁/共67頁Treatment

OfficeandMinorProceduresRubberbandligationPerformedintheofficeIndicatedforGrade1and2internalhemorrhoidsBandisappliedthroughananoscopeatthetopofaninternalhemorrhoidSevereperianalsepsis–ClassicTriadDelayedanalpainUrinaryretentionFever第48頁/共67頁Treatment

OfficeandMinorProceduresInfraredPhotocoagulationIndicatedin1stdegreehemorrhoidsCausesphotocoagulationofsmallvesselsPerformedinofficeor“HemorrhoidReliefCenter”Minimalpain第49頁/共67頁ClosedHemorrhoidectomy

IndicationHemorrhoidsareseverelyprolapsedandrequiremanualreplacementPatientsfailtoimproveaftermultipleapplicationsofnon-operativetreatmentHemorrhoidsarecomplicatedbyassociatedpathologysuchasulceration,fissure,fistula,largehypertrophiedanalpapillaorextensiveskintags第50頁/共67頁ClosedHemorrhoidectomy

GeneralPrincipleMostcanbeperformedwithlocalandIVSedationProne/KraskepositionisthebestInfusetheareawithlocalanestheticwithepinephrineforhemostasisFleetsenema1-2hourspriorNoantibioticprophylaxisisnecessary第51頁/共67頁ClosedHemorrhoidectomy第52頁/共67頁ClosedHemorrhoidectomy第53頁/共67頁ClosedHemorrhoidectomy

PostopResult第54頁/共67頁P(yáng)PHStaplingProcedureforHemorrhoidsNotforeveryhemorrhoidIdealforGrade2and3withminimalexternalcomponentPreventsprolapseandthuslesstraumatohemorrhoidwithbowelmovement第55頁/共67頁第56頁/共67頁P(yáng)PHStaplingProcedureforHemorrhoids第57頁/共67頁P(yáng)PHStaplingProcedureforHemorrhoidsBenefitsLesspainascomparedtotraditionalclosedhemorrhoidectomyLessbloodlossduringtheprocedureLesschanceofanalstenosis第58頁/共67頁P(yáng)PHStaplingProcedureforHemorrhoidsRisksIfstapleplacedtoolow–severechronicpainandincontinenceIfstaplelineplacedtoohigh–failuretorelie