DIAGNOSIS AND MANAGEMENT OF COMMON ANORECTAL DISORDERS. Lisa Coleman, DO, FASCRS, FACS Center for Colorectal Surgery TPMG Retreat 2017

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1 DIAGNOSIS AND MANAGEMENT OF COMMON ANORECTAL DISORDERS Lisa Coleman, DO, FASCRS, FACS Center for Colorectal Surgery TPMG Retreat 2017

2 The Heinous Anus

3 Anal Abscess Anal Cancer Anal Fissure Anal Warts Cancer of the Anus Cancer of the Rectum Condyloma Cryptitis Enlarged Papillae Fecal Incontinence Fissure Fistula-in-ano Hemorrhoids Levator Syndrome Pilonidal Cyst Polyps Procidentia Proctalgia Fugax Proctitis Pruritus Ani Rectal Prolapse Rectocele Warts Venereal

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5 ANORECTAL ANATOMY

6 SYMPTOMS AND SIGNS Symptoms Pain Bleeding Protrusion Seepage & Soilage Itching Change in BM Signs Tenderness Fluctuance Erythema Mass

7 EVALUATION Patient reluctance Fear of pain Fear of cancer Physician responsibility Place the patient at ease Impart concerned, attentive, and confident attitude

8 EVALUATION Patients lack of knowledge of the anorectal region results in every symptom being attributable to hemorrhoids Exclusion of a proximal malignancy should be considered Most patients with anorectal complaints should undergo some form of proctosigmoidoscopy during their evaluation and treatment

9 Habitual 1. Constipation and straining 2. Low fibre high fat/spicy diet 3. Prolonged sitting in toilet 4. Pregnancy 5. Aging 6. Obesity 7. Office work 8. Family tendency Pathological 1. Chronic diarrhea (IBD) 2. Colon malignancy 3. Portal hypertension 4. Spinal cord injury 5. Rectal surgery 6. Episiotomy 7. Anal intercourse

10 EVALUATION

11 EVALUATION

12 EVALUATION Positioning Simms Prone

13 EVALUATION Inspection

14 EVALUATION Palpation

15 EVALUATION Inspection External inspection: Piles. Skin tags (normal, Crohn's, hemorhoids). Rectal prolapse. Anal fissure. Fistula. Anal warts. Carcinoma. Signs of incontinence, diarrhea. External inspection (straining): Ask pt. to strain. Rectal prolapse upon straining. Hemorrhoid prolapse. Incontinence. Ask if straining is painful

16 EVALUATION Proctoscopy Anoscopy Flexible Endoscopy

17 SPECIFIC DISORDERS Hemorrhoids Fissure Fistula & abscess Condyloma Rectal Prolapse Fecal incontinence Pilonidal disease Hidradenitis suppurativa Pruritus ani Anal neoplasms

18 HEMORRHOIDS Prevalence 4.4 % of US populations seen by physician for symptomatic hemorrhoids 49/100k US population undergo hemorrhoidectomy annually

19 HEMORRHOIDS Etiology Elevated intra-abdominal pressure Pregnancy Constipation Weight lifting Chronic straining All lead to sliding down of the cushions, stretching of the muscular support, and prolapse

20 HEMORRHOIDS Function Aid in continence Act as a plug Protect sphincters/anus from the trauma of defecation

21 HEMORRHOIDS Anatomy External hemorrhoids Distal to the dentate line Squamous epithelium(skin) Nerve endings Internal hemorrhoids Proximal to the dentate line Columnar epithelium(mucosa) No nerve endings

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23 HEMORRHOIDS Internal Bleeding Protrusion Seepage/soilage Staining Pruritus Rarely painful Symptoms

24 INTERNAL HEMORRHOIDS Grade I No prolapse Grade II Prolapse and reduces spontaneously Grade III Prolapse and needs manual reduction Grade IV Does not reduce

25 INTERNAL HEMORRHOIDS Indications for Therapy Failure of conservative measures High fiber diet Plenty of fluids Fiber supplements Stool lubricants/softeners Continued symptoms Bleeding Protrusion Pruritus/irritation Pain Seepage and soilage Difficulty with hygiene

26 INTERNAL HEMORRHOIDS Management Office based procedures Rubber band ligation(rbl) Injection sclerotherapy Infrared coagulation Bicap Sonographic ligator Surgical procedures Excisional hemorrhoidectomy THD Stapled Anopexy PPH

27 INTERNAL HEMORRHOIDS Management Decisions Grade I: RBL or sclerotherapy Grade II: RBL Grade III: RBL or hemorrhoidectomy Grade IV: Hemorrhoidectomy Mixed Int & ext: Hemorrhoidectomy

28 INTERNAL HEMORRHOIDS

29 INTERNAL HEMORRHOIDS Surgical Options Excisional Cold Scissors, Laser, Harmonic Scalpel, LigaSure

30 Internal Hemorrhoids

31 Internal Hemorrhoids - PPH

32 INTERNAL HEMORRHOIDS Surgical Outcomes Painful Bloody Complications Hemorrhage Infection Urinary retention Fecal impaction Anal stricture Sphincter injury/incontinence Wet anus/ectropion Chronic pain

33 HEMORRHOIDS Symptoms External Protrusion/lump Pain if thrombosed Seepage/soilage Staining Pruritus Bleeding only if ruptured

34 EXTERNAL HEMORRHOIDS Management Symptomatic relief Sitz baths Stool softeners Pain medications Excision Thrombectomy

35 External Hemorrhoids

36 Thrombosed Ext Hemorrhoid

37 Thrombosed Ext Hemorrhoid

38 Females 90% posterior 10% anterior Males 99% posterior 1% anterior Distal to dentate line ANAL FISSURE Anatomy

39 Trauma ANAL FISSURE Etiology Large hard stool Diarrhea Hypertonic/hyperspastic internal sphincter Diminished blood flow/ischemia

40 Anal Fissure: By Location Leukemia, Trauma, Dermatopat hy Posterior: Hard Stool Trauma Diarhea Crohn s UC, TB, HIV Syphilis, Anterior: CA Hard Stool Trauma, Dia

41 Pain Spasm Common Anorectal Disorders Bleeding Seepage/soilage Difficult evacuation ANAL FISSURE Symptoms

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43 ANAL FISSURE Chronic Sentinel skin tag Hypertrophic papilla Exposed IAS Hyperspastic IAS Anal stenosis Fistula

44 Classic Presentation

45 ANAL FISSURE Management Symptomatic relief Sitz baths Stool softeners Pain medications Topical nitroglycerin Botox injection Lateral internal sphincterotomy Anoplasty Fissurectomy Anal Stretch

46 ANORECTAL SUPPURATION Acute: abscess

47 ANORECTAL SUPPURATION Etiology Cryptoglandular Carcinoma Crohn s disease Foreign body Trauma Surgery Radiation Tuberculosis Actinomycosis LGV

48 ANORECTAL SUPPURATION Abscesses: Classification

49 ANORECTAL SUPPURATION Abscess: Symptoms Pain Swelling Drainage Bleeding Constipation Urinary difficulties

50 ANORECTAL SUPPURATION Management Antibiotics Sepsis Cellulitis Immunosuppression DM HIV Prostheses Valvular Joint Intravascular

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52 ANORECTAL SUPPURATION Fistulae: Classification

53 External Opening Fistula-in-Ano

54 ANORECTAL SUPPURATION Chronic: fistula

55 ANORECTAL SUPPURATION Management Abscess Drainage Fistula Fistulotomy Seton (draining vs cutting) Staged fistulotomy Mucosal advancement flap Anoplasty Fibrin glue

56 Fistulotomy

57 Seton

58 Fistula Plug

59 L.I.F.T. Procedure

60 Rectal Prolapse Symptoms Incontinence Constipation Protrusion Bleeding Discharge Sensation of incomplete emptying Rectal pressure/tenesmus

61 Rectal Prolapse Rectal prolapse is the abnormal movement of the rectal mucosa down to or through the anal opening. Mucosal prolapse Complete rectal prolapse

62 Rectal Prolapse Pathophysiology Rectal intussusception Deep cul de sac Loss of rectal fixation Redundant sigmoid Levator ani diastasis Patulous anal sphincter Pudendal neuropathy

63 Mucosal Prolapse (Hemorrhoids)

64 Rectal Prolapse Complete Procidentia (Early)

65 Rectal Prolapse Complete Procidentia (Late)

66 Rectal Prolapse Complete Procidentia (Too Late)

67 Rectal Prolapse Treatment Abdominal repair Rectal fixation Sigmoid resection Proctectomy Combination of rectal fixation and sigmoid resection Perineal repair Full thickness resection Mucosal resection with muscular reefing Anal encirclement

68 Pruritis Ani Anal itching and burning elicited by local irritation from excoriation, secretions, and/or irritants

69 Pruritis Ani Etiology Seepage/Soilage Poor hygiene Excessive cleansing Soaps, ointments, perfumes Dietary agents Caffeine Citrus Tomatoes Spices Beer Obesity/Tight fitting clothes Anorectal pathology Diarrheal states Pelvic radiotherapy Dermatologic conditions Perianal infections Systemic diseases Medications Idiopathic

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71 Anal Fissure due to Pruritis Ani

72 Pruritis Ani Treatment Alterations in hygiene Dietary manipulation Bulking regimen(psyllium) Treat underlying causes Surgical correction of specific anorectal disorders Avoid scratching

73 Hidradenitis Suppurativa An acute or chronic infection of the apocrine sweat glands Results in abscess and sinus tract formation May occur in the neck, axilla, inframammary folds, groins, genitals, perianal region, scalp, and periumbilical region

74 Hidradenitis Suppurativa Obesity Heavy perspirers African American race Mechanical irritation Local trauma Risk Factors

75 Hidraadenitis Suppurativa Treatment Good hygiene Antibiotics Incision and drainage of abscesses Wide excision Unroofing of tracts

76 Pilonidal Disease Etiology Congenital theory Remnants of the medullary canal Developemental dermal inclusions Vestigal sex glands Acquired theory Reaction to imbedded hair Infection within an occluded hair follicle The presence of hair perpetuates the process

77 Pilonidal Disease Presentation Acute Pilonidal abscess Chronic Pilonidal sinus

78 Pilonidal Disease Treatment Pit excision Cystotomy Wide local excision With or without closure Lateral excision Flaps Cleft closure

79 Bilateral V-to-Y Flaps

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82 Presentation Evaluation Specific disorders Workup Treatment

83 Transition Zone Anal Region Anatomy Anal Margin

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85 SYMPTOMS Pain Sharp / dull / burning Associated with bowel movements Constant / intermittent Associated with activity Associated with bleeding

86 SYMPTOMS Bleeding Bright / dark On paper / in bowl / on stool / in stool Black, tarry stools Associated with bowel movements Associated with pain

87 HEMORRHOIDS Vascular cushions Blood vessels Connective tissue Smooth muscle Constant position Left lateral Right anterior Right posterior Anatomy

88 ANORECTAL SUPPURATION Etiology

89 Perianal Abscess

90 Drained Perianal Abscess

91 Perianal Abscess

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93 Classification of Anal Fistulae

94 Rectal prolapse Mucosal prolapse is more often seen in children below 3 yrs of age following an attack of diarrhoea or whooping cough, and if it occurs in adult is usually associated with haemrrhoids. Complete rectal prolapse is seen more commonly in elderly women who have a habit of excessive straining during defecation. Rectal prolapse is often associated with other conditions such as: * Pinworms(Enterobiasis) * Cystic fibrosis * Malnutrition and malabsorption (Celiac disease) * Constipation * Prior trauma to the anus or pelvic area

95 Rectal prolapse Symptoms:The main symptom is a protrusion of a reddish mass from the anal opening, especially following a bowel movement. Treatment : * Treating the underlying condition * In children, Conservative treatment * The rectal mass may be returned to the rectum manually * Surgical correction for complete rectal prolapse Complications * Constipation * Malnutrition or malabsorption * Other complications of underlying condition

96 Rectal Prolapse Prolapse Evaluation Hemorrhoids Examination on the commode may be crucial

97 Rectal Prolapse Complete Procidentia (Early)

98 Condyloma Acuminata Sexually transmitted Human papilloma virus 66 known types Types 16 & 18 Dysplasia Malignancy 1 million new cases diagnosed annually Etiology

99 Condyloma Acuminata Risk Factors Homosexual males Anoreceptive intercourse Immunosuppression HIV

100 Condyloma Acuminata Symptoms Visible/palpable warts Pruritus Seepage/soilage Bleeding Wetness Discomfort

101 Condyloma Acuminata Management Caustic agents Podophyllin Bichloroacetic acid Trichloroacetic acid Surgical Excision Fulguration Laser therapy Cryotherapy Immunotherapy Autologous vaccines Imiquamod(Aldara) Interferon Chemotherapeutics 5-FU Bleomycin Thiotepa

102 Condyloma Acuminata Management Recurrence rates: 8-40% Anal canal lesions present in 35-45% of patients Treatment of perianal lesions without treatment of anal canal lesions and partner(s) is doomed to failure