Benign anorectal diseases

Transcription

1 Benign anorectal diseases

2 Symptoms Bleeding Pruritus Discharge Fecal incontinence Diarrhea Constipation False need to defecate

3 Examinations Clinical exam Anuscopy Rectosigmoidoscopy Endosonography MRI Manometry MR Defecography

4 Proctological examination

5

6 High resolution anoscopy For patients with increased risk of anal cancer and abnormal anal cytology 1. MSM-HIV positive 2. HIV patients 3. Transplant patients 4. Women with a history of lower genital tract dysplasia

7 High resolution anoscopy-for detection of high grade squamous intraepithelial lesions An anoscope is inserted and a colposcope is used for the examination of the squamocolumnar junction, the transformation zone and the perianal skin Application of acetic acid 3% or 5% Lugol iodine solution

8 HSIL Flat or thickened Often with vascular changespunctuation or mosaic pattern Acetowhite Poor uptake of Lugol

9 High resolution anoscopy

10 High resolution anoscopy-lugol

11 High resolution anoscopystaining with Lugol

12

13 Hemorrhoids

14 Hemorrhoids Diagnosis and treatment are based on symptoms rather than appearance Therapy should be guided by two principles 1. Colonic or rectal disease must be excluded 2. Asymptomatic hemorrhoids should not be treated

15 Treatment of hemorrhoids Conservative management Endoscopic treatment Surgical treatment

16 Pay attention-defecation habit-3 errors Insistence in having at least one bowel movement daily Neglect of first urge to defecate in the morning Insisting on trying to pass the last portion of stool from the rectum to anal canal, to prevent the peristence of discomfort

17 Complication and treatment Thrombosis

18 Endoscopic treatment of hemorrhoids Hemorrhage

19 Rubber band ligation Placing a rubber band ar the base of a hemorrhoid In second degree hemorroids At the anorectal junction immediately above the internal hemorrhoid Application that is too low, near the dentate line and too deep induce pain!!! Only one to two areas should be banded at a time to prevent severe discomfort New session after 3-6 weeks Low rate of complication: liver abscess, clostridial sepsis, soft tissue infections andbacterial sepsis or toxemia

20 Infrared coagulation Thermal necrosis followed by ulceration, which heals by cicatrisation in 2-3 weeks The scar fixes the mucosa to the underlying tissue and prevents prolapse Two sessions: coagulate at 2, 4, 8 and 10 o clock and 3, 6, 9, 12 o clock Postoperative pain and secondary bleeding are rare Cure at 12 months can be achieved in 75% of first and secind degree hemorrhoids 15% recurrence in 3 years

21 Skin tags Usually not symptomatic Folds of skin

22 Hypertrophic anal papille

23 Anal fissures Acute-mostly heal spontaneously Chronic-persistence beyond 6 weeks, morphologically-presence of visible transverse internal anal sphincter fibers at the base of the fissure Associated signs in chronic fissures: indurated edges, a sentinel pile and a hypertrophied anal papilla

24 Typical Atypical or multiple Posterior midline 75% Anterior midline 25% Posterior and anterior 3% Crohn Disease Trauma Tuberculosis Syphilis AIDS Anal carcinoma Anal fissures

25 Treatment of anal fissures Nitric oxide donors-glyceril trinitrate 0.2% up to 8 weeks Calcium channel blockers topical nifedipine, topical diltiazem (heal between 48 and 75% of fissures that fail GTN Botulinum toxin A-injection into the internal anal sphincter-safe drug in short and medium therm Surgical therapies

26 Abscesses and anal fistulas Anorectal abscesses frequently result in more or less complex and extensive fistulous tracts The two pathologies should be regarded as the same condition Primary septic lesions have a cryptoglandular origin-90% of fistulas

27 Symptoms Discomfort, perianal pain and swelling-aggravating by sitting,walking and defecation Sometimes minor anal bleedingand discharge if small amount of pus Superficial cellulitis Fever, chills, malaise

28 Diagnosis of abscess and fistulas Clinical exam Endosonography MRI

29 Sometimes anorectal examination with a rigid instrument To identify the anal crypt responsible for the infection To determine the prsence of underlying septic or inflammatiry proctitis To look for a perforated anorectal cancer

30 Classification of anal abscesses

31 Fistula

32 Anal abscess

33 Anal fistula

34 Seton drainage

35 Condyloma acuminata Due to HPV infection Some serotypes /high potential of malignancy HPV 16 and 18!!! Perianal and/or intraanal-examination of anal canal!

36 Condyloma acuminata high resolution anoscopy( a.acetowhitening b.treatment with trichlor acetic acid 85%)

37 Condyloma planum

38 Therapy Podophyllin diluted to 15-20%-when the lesions are few and small Cryosurgery, electrosurgery, laser treatment Clinical trials with interferons(alpha, gamma) Local immunostimulation with imiquimod

39 Perianal hidrosadenitis suppurativa

40 Perianal hidrosadenitis suppurativa Chronic recurrent inflammatory disease of apocrine glands, adjacent anal canal skin and soft tissues Sometimes associated with Crohn disease