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Anal Canal Fissure In Ano Haemorrhoids PowerPoint Presentation

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Description : Check out this medical presentation on Rectal Problems, which is titled "Anal Canal Fissure In Ano Haemorrhoids", to know about Anorectal Anatomy and Anal Canal Fissure.

Tags : Rectal Problems, Anal Canal Fissure, Ano Haemorrhoids, Anorectal Anatomy

Published on : Jul 10, 2021 | Views : 2773 | Downloads : 9

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Slide 1-

Anal Canal Fissure In Ano Haemorrhoids Dr.Amit Gupta Associate Professor Dept. of Surgery
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Anorectal Anatomy Anal verge Anal canal Arterial Supply Inferior rectal A middle rectal A Venous drainage Inferior rectal V middle rectal V 3 hemorrhoidal complexes L lateral R antero-lateral R posterolateral Lymphatic drainage Above dentate: Inf. Mesenteric Below dentate: internal iliac Nerve Supply Sympathetic: Superior hypogastric plexus Parasympathetic: S234 (nerviergentis Pudendal Nerve: Motor and sensory
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External Internal Anoderm Swell, discomfort, difficult hygiene Pain? -> Thrombosed Pain? -> painless Bright red bleeding Prolapse associated with defecation
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Background They are part of the normal anoderm cushions They are areas of vascular anastamosis in a supporting stroma of subepithelial smooth muscles. The contribute 15-20% of the normal resting pressure and feed vital sensory information . 3 main cushions are found L lateral R anterior R posterior But can be found anywhere in anus Prevalence is 4% Miss labelling by referring physicians and patients is common This combination is only in 19%
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3 main processes: Increased venous pressure Weakness in supporting fibromuscular stroma Increased internal sphincter tone Pathogenesis
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Risk factors
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Classification
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Thrombosed external piles
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First-degree internal piles viewed through anoscope
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Second-degree internal prolapsed piles, reduced spontaneously
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Third-degree internal prolapsed piles, requiring manual reduction
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Fourth-degree strangulated internal and thrombosed external piles
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Clinical assessment
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Lab: CBC / Clotting profile/ Group and save Proctography: if rectal prolpse is suspected Colonoscopy: if higher colonic or sinister pathology is suspected Investigations
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Thrombosed internal haemorrhoids Thrombosed external haemorrhoids Complications Ulceration Thrombosis Sepsis and abscess formation Incontinence
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Internal Haemorrhoids Treatment
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Excision of thrombosed external hemorrhoid.
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Closed hemorrhoidectomy
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Grade 4 hemorrhoid before reduction Placement of stapling device obturator Stapling device
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If presentation less than 72 hours: Enucleate under LA or GA Leave wound open to close by secondary intension Apply pressure dressing for 24 hours post op If more than 72 hours: Conservative measures External Haemorrhoids Treatment
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Anal Fissure Linear tears in the anal mucosa exposing the internal sphincter 90% are posterior
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Young & middle aged adults Male = Female Location – posterior midline (most common) Anterior midline fissures – more common in females In any event, length of each fissure is remarkably constant, extending from the dentate line to the anal verge and corresponding roughly to the lower half of the internal sphincter
Slide 26-

Pathology Acute fissures – heal promptly with conservative treatment Secondary changes if present, it does not heal readily Sentinel pile Hypertrophied anal papilla Long standing Fibrous induration in lateral edges of fissure Fibrosis at the base of ulcer (internal sphincter) At any stage Frank suppuration – intersphincteric / perianal abscess
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Etiology Initiation – trauma Why midline posterior fissures are more common? Dietary factors Decreased risk – raw foods, vegetables, whole grain bread Increased risk – white bread sausages etc. Secondary fissure Crohn’s disease Previous anal surgery, especially hemorrhoidectomy Fistula-in-ano surgery Anterior fissure in females resulting from childbirth Long standing loose stools with chronic laxative abuse
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Initiation – trauma Perpetuation of fissure – abnormality of internal anal sphincter Higher resting pressure within the internal anal sphincter in pts with fissures than in normal control Rectal distension  reflex relaxation of internal anal sphincter  overshoot contractions in these patients  sphincter spasm and pain Elevated sphincter pressures cause ischemia of the anal lining resulting in pain and failure to heal Posterior commissure perfused more poorly than the other portion of the anal canal
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Clinical Features Pain and spasm Sharp, agonizing during defecation, recurrent, worsens constipation. Bleeding In small amounts, approximately 70% of patients note bright red blood on the toilet paper or stool Discharge Irritation and pruritis ani due to malodorous discharge of the pus Constipation Painless non-healing fissure with occasional bleed – may be a progenitor of IBD
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Diagnosis Inspection – Acute fissure is seen as Linear tear most important Palpation Anoscopy Sigmoidoscopy Biopsy
Slide 31-

Differential diagnosis Anorectal suppuration Pruritus ani Fissure in inflammatory bowel disease Carcinoma Syphilitic fissures Tuberculous ulcer Anal abrasion
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Treatment Acute Fissure Stool-bulking agents Warm sitz bath Healed (80%) Non-healed (20%) 0.2% Nitroglycerin or 2% Nifedipine or Diltiazem 4-6 wks Repeat treatment with alternate medication Non-healed (30%) Healed (70%) Chronic fissure Botulinum toxin A injection Open LIS 98% healing Closed LIS
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Acute anal fissure: Spontaneous healing, High fiber diet, adequate water intake and warm sitz bath, stool softener/bulk laxative, suppositories Sodium tetradecyl sulphate
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Chronic anal fissure: Conservative Surgical
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Pharmacological Sphincterotomy Pharmacological manipulation of anal sphincter tone as an alternative modality to surgery for the treatment of anal fissure Shares the same goal as lateral sphincterotomy without its possible long-term side effects Pharmacological agents lower anal canal resting pressure producing chemical sphincterotomy without causing permanent damage to the anal sphincter mechanism
Slide 36-

By enhancing internal anal sphincter (IAS) relaxation via nitric oxide donation intracellular Ca2+ depletion muscarinic receptor stimulation adrenergic inhibition This improves blood supply at the site of the fissure that would promote healing of anal fissures Nitric oxide donors and calcium channel blockers, agents that directly reduce resting anal pressure, has now largely replaced traditional surgical methods as first-line treatment for chronic anal fissure
Slide 37-

Botulinum Toxin A L-arginine Gonyautoxin Topical sildenafil Other Agents